Task 1: Federal Government Payer Program

A. Analyze one federal government payer program for healthcare services (i.e., Medicare, Federal

Employees Health Benefits Program, Indian Health Service, or TRICARE) making an impact on today’s

healthcare ecosystem by doing the following:

1. Explain how your chosen federal government payer program impacts licensure, certification, or

accreditation standards.

2. Explain how your chosen federal government payer program influences each of the following:

a. clinical quality reporting systems

b. reimbursement for healthcare services

c. patient access to care

B. Evaluate how health information management plays a part in your chosen federal government payer

program by discussing a specific professional role within the HIM profession and how the role supports

the goals of the chosen federal government payer program.

C. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted,

paraphrased, or summarized.

Expert Solution Preview

Introduction:
The federal government has several payer programs for healthcare services. These programs impact the healthcare ecosystem in many ways, including licensure, clinical quality reporting systems, reimbursement for healthcare services, and patient access to care. In this answer, we will analyze one federal government payer program and evaluate how health information management plays a role in this program.

A.
The chosen federal government payer program for this analysis is Medicare. Medicare is a federal health insurance program that provides coverage for individuals who are over 65 years old, people with disabilities, and individuals with end-stage renal disease. The impact of Medicare on the healthcare ecosystem can be described as follows:

1. Medicare impacts licensure, certification, or accreditation standards. Medicare’s conditions of participation (CoPs) are comprehensive and cover several aspects of healthcare delivery. Health care providers who participate in Medicare need to comply with the CoPs that relate to their specific healthcare delivery setting. Thus, Medicare has a significant influence on licensure, certification, or accreditation standards.

2. Medicare influences the following:

a. Clinical quality reporting systems: Medicare has several initiatives that aim to improve the quality of healthcare delivery. For example, the Physician Quality Reporting System (PQRS) encourages physicians to report on quality measures. The Hospital Inpatient Quality Reporting (IQR) program incentivizes hospitals to report on quality measures as well.

b. Reimbursement for healthcare services: Medicare provides reimbursement for healthcare services through several different payment systems. The most common one is the Medicare Fee-for-Service (FFS) payment system, where the provider bills Medicare for each service provided. Medicare Advantage plans, which are managed care plans, pay providers using a capitated payment system.

c. Patient access to care: Medicare provides access to healthcare services to millions of people who would not be able to afford healthcare otherwise. This access to care ensures that Medicare beneficiaries receive appropriate healthcare services when needed.

B.
Health information management (HIM) plays a vital role in Medicare. A specific professional role within the HIM profession that supports Medicare’s goals is the Clinical Documentation Improvement (CDI) Specialist. CDI specialists work to ensure that the documentation in the medical record accurately reflects the care that was provided to the patient. Accurate documentation is essential for proper coding and billing of healthcare services. CDI specialists also provide education to healthcare providers on documentation best practices and ensure compliance with Medicare’s CoPs.

C.
Sources:
Centers for Medicare & Medicaid Services. (n.d.). About Medicare. Retrieved from

Centers for Medicare & Medicaid Services. (n.d.). Conditions of Participation (CoPs). Retrieved from

American Health Information Management Association. (n.d.). Clinical Documentation Improvement. Retrieved from

American Health Information Management Association. (n.d.). Role of Health Information Management in Medicare’s Quality Payment Program. Retrieved from

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