Week 4 Discussion HCAD 650

Week 4 Discussion HCAD 650

Medicare and Interoperability

Medicare and Interoperability are essential aspects in the health and medical field. According to the U.S. Department of Health and Human Services (2015), Medicare is a health insurance program meant for individuals who are older than 65 years, children with disabilities, and individuals who have End-Stage Renal Disease. On the other hand, Interoperability can be understood according to the U.S. Department of Health and Human Services (2015) as the ability of different health information technology and software systems to swap and utilize the information. The medical environment is complex, surrounded by various activities in different settings; thus, integrating the health information system is vital to building perpetual possibilities for the healthcare industry. In general, developing Medicare and Interoperability aims to motivate eligible experts and qualified health centers to embrace, implement, upgrade, and show a magnificent use of health technology. Nevertheless, Medicare and Interoperability are guided by various rules, which ensure proper implementation of its activities.?? ?????

? Part 1: Critical Analysis of the Law

??????????? Hospitals taking part in Medicare must meet some conditions specified in the Social Security Act. Also, the health, education, and welfare departmental secretary has the authority to impose additional needs necessary to ensure the safety and health of Medicare beneficiaries. According to CMSHHSgov (2015), the conditions for various hospitals participating in Medicare include a hospital medical staff meeting the standard calling for a systematic commitment to analyze, review, and evaluate the clinical activities using appropriate evaluation techniques. Also, the hospitals are expected to have the desired performance and outcome to help improve administrative flexibility. Ideally, being under Medicare authority, hospitals enjoy several advantages, including low monthly premiums and Broad acceptance. According to CMSHHSgov (2015), part A of Medicare is usually premium-free for most individuals. Again, regarding Broad acceptance, Medicare gives more flexibility in choosing the healthcare provider. However, Medicare can have some disadvantages. Normally, even after individuals meet the deductibles for premium-free part A, the out-of-pocket costs of Medicare tend to increase so fast.

??????????? Furthermore, the non-participants of Medicare can incur some consequences. For instance, according to Showalter (2020), non-participants of Medicare can be charged up to about 15% more than approved medical individuals. In short, the non-participants of Medicare are responsible for about 35% of the approved Medicare amount for the services covered. The Joint Commission has specific roles that would help obtain "deemed" status. To help bring the deemed status, the Joint Commission permits the health care cooperation and various agencies participating in Medicare-like home health agencies and hospitals, to automatically qualify for the federal requirement exemption participation. As a matter of clarity, the Joint Commission is not a government regulatory agency ("Importance of the COSO internal control framework," 2013). The commission cannot fine the healthcare corporations for failing to meet the standard. The COSO Framework can be understood as a system created purposefully for internal controls to be included in business procedures. COSO can meet Medicare CoP in several ways, including adopting technologies, preventing fraud, and improving the reliability of money reporting.

Part 2:? Strategic Compliance with the Law

??????????? For many reasons, the Centers for Medicare and Medicaid Services (CMS) and the Recovery Audit Contractor (RAC) may have the right to access individuals' medical records. First, access to people's medical records by CMS and RAC is necessary because it helps them identify medical underpayments and overpayments to suppliers and providers of healthcare. One legal act defining these rights of CMS and RAC is the 2006 Tax Relief and Health Care Act (Kinney, n.d.). Furthermore, when an individual's records are electronic yet not transferable in an interoperable fashion, there are still some means by which a person can meet the request of the medical record. One can use the paper record as an alternative to electronic records. According to Gillen et al. (2018), Electronic Medical Records (EMR) give power to health providers to convert medical information to paper format. The paper record helps in situations where electronic records are inaccessible.

??????????? Interoperability requirements are the possibility of sharing data and services. Generally, understanding the rate at which the information should be shared is crucial, particularly in a complicated corporation. To have an interoperable electronic health record based on CMS standards, one should perform risk assessment, properly utilize Encryption, and check the audit logs (Gillen et al., 2018). Again, achieving Interoperability involves different steps, including adopting and optimizing the health information exchange and electronic health records services. Other measures include consolidating the hardware, consolidating information, and maintaining proper communication with the vendors.

??????????? If one disagrees with the auditor's conclusion, there are still other options to contest the findings of RAC. For instance, if a person does not agree with the received letter demanding overpayment, there is an option of appealing. According to CMSHHSgov (2015), the first appeal is redetermination, and the second level of appeal is reconsideration. Generally, the best action through which I would recommend someone to contest the findings whose large recoupment is due to CMS is still through appealing.?????

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References

CMSHHSgov. (2015, April 30).?Medicare & You: Understanding Your Medicare Choices.?https://www.youtube.com/watch?v=WZVQSFBq2uw

Gillen,?E., Berzin,?O., Vincent,?A., & Johnston,?D. (2018). Certified electronic health record technology under the quality payment program.?https://doi.org/10.3768/rtipress.2018.pb.0014.1801

Importance of the COSO internal control framework. (2013).?Executive's Guide to COSO Internal Controls, 1-4.?https://doi.org/10.1002/9781118691656.ch1

Kinney,?E.?D. (n.d.). The impact of the Affordable Care Act on the Medicare program.?The Affordable Care Act and Medicare in Comparative Context, 305-321.?https://doi.org/10.1017/cbo9781316275245.013

Showalter?S. (2020).?Chapter 2 ACCESS TO HEALTHCARE: RIGHTS AND RESPONSIBILITIES. The Law of healthcare.

U.S. Department of Health and Human Services. (2015, July 28).?50th Anniversary of Medicare & Medicaid: 50 Years, Millions of Healthier Lives.?https://www.youtube.com/watch?v=JK4nBk2-_Wo