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Health, Medicine, Nursing
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MEDICARE (Essay Sample)

In light of Medicare's part A and Part B, there are two parts to this case assignment. A. Mrs. Anderson is 69 years old and hospitalized for Nasal Trauma. Due to complications, she stayed in the hospital for 70 days and received extra medical services. General Hospital is a large urban hospital in San Francisco, that incurred $125,000 in Medicare approved charges in treating Mrs. Anderson. Following treatment at General Hospital, Mrs. Anderson was required to stay at a skilled nursing facility for 30 days. Using the information provided in this module (including the outlier example in the required reading) and the links to websites answer the following questions: 1. What is the operating payment to be paid to the hospital? 2. What is the capital cost payment to be paid to the hospital? 3. What Cost Outlier payments will the hospital be eligible for? 4. What is the total payment to the hospital? 5. What is the payment for the skilled nursing facility? B. Now that you have calculated reimbursement for Mrs. Anderson's hospital and SNF stay, the second part of this assignment will focus on physician reimbursement. Assume the following values for the services provided by the physician: Categories RVU Geographic Cost Index Product Conversion Factor Work 27.45 1.092 29.98 - Practice Expense 43.05 1.743 75.04 - Malpractice 10.32 0.543 5.60 - - - - 110.62 64.43 Calculate physician reimbursement for all three types of physicians. Also, calculate the out of pocket payments that Mrs. Anderson will be responsible for. Medicare Example source..
Medicare is a program on health insurance that provides coverage for individuals aged 65 years and above and to individuals under 65 years with permanent disabilities provided they are entitled to receive Social Security Disability Insurance or Railroad retirement Disability Benefits. Individuals who have special health problems can also receive this insurance coverage (Medicare Coverage, 2008). The insurance program has two major benefits which include:
This program covers services for inpatient stays at the hospital and for post hospital care in a nursing facility provided: The patient has stayed in the hospital for a minimum of three days, the ailment had been diagnosed in the period of the stay in the hospital, the ailment needs the supervision of a skilled nurse and provided the services offered are skilled (Medicare Coverage, 2008).
In the example Mrs. Anderson is entitled to part A of Medicare insurance cover because she is over 65 years and had been hospitalized. Further she has been confined to a skilled nursing facility for a period of 30 days due to complications that arose during her hospital stay.
The following are the payments to be paid to the hospital:
1 Operating payment = Billed charges x Operating Cost to Charge Ratio
= $ 125,000 x 0.38
= $ 47,500
2 Capital cost payment= Billed charges x Capital Cost to Charge Ratio
= $ 125,000 x 0.04
= $ 5,000
3 Cost Outlier payment that the hospital is eligible for
Operating CCR to Total CCR = Operating CCR / (Operating CCR + Capital CCR)
= 0.38 / (0.38 + 0.04)
= 0.9048
Capital CCR to Tot...
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