Accounting Implications and Payer Organizations, Research Paper Example

The implications that the Patient Protection and Affordable Health Care Act of 2010 will have on the accounting processes of health care facilities will be reviewed in this research paper (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;. Manchikanti & Hirsch, 2012). The stages of the Patient and Affordable Health Care Act of 2010 and the novel implementations for 2014 will be explored. The Patient and Affordable Health Care Act of 2010 is founded upon the regulation of the medical industry by the federal government (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012). There are certain sections of the Patient Protection and Health Care Act of2010 which were implemented immediately.

Patient Protection Initiatives

There are sections of the ACAwhich will not become effective until 2014. The federal legislation which is incorporated in the PatientProtection and Affordable Health Care Act of 2010provides health care availability to nearly all of the population of the United States. The provisions which had been established for maintaining a pre- existent condition in order to receive health care services has been eliminated. The threshold age for the coverage of dependents has been augmented to twenty six years of age.  The claims capability of the preceding health care systems has been modified (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

The application of deductibles has received more stringent limitations under the Patient Protection and Affordable Health Care Act. One of the primarycharacteristics is the eradication of the patient provisions on restrictions of the quantity of lifetime health care which may be received by the patient. Another restriction which has been lifted by the ACA is the pre- existent health care conditions for all of the health care benefits plans. The capacity of the health care provider to rescind for nonpayment or fraudulent representation has been eliminated (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

Claims Processing

The conventional claimscapacityof the ACA requires the collection of operational functions which are in the organization that is providing payment for the health care services that process the claims in conjunction from the receipt of the claim to the provision of payment and the estimate of the benefits (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;. Manchikanti & Hirsch, 2012). The collection of the operational functions incorporates the following steps:

1. Receiving the claim which has been submitted electronically by mean of the EDI (electronic data interchange).
2. Receiving the claims as it is detailed on paper.
3. Initial claims adjustment.
4. Secondary claims adjustment which is subsequent to any items which may be questionable.
5. Physical processing of the claims which cannot be adjusted electronically.
6. Issuance of the check.
7. Explanation of benefits issuance and the remittance advice.
8. The fulfillment of the post analytic and prepayment process.
9. The data storage of the claim data and records (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

More frequently, the set of functions are detailed as claims by the personnel within and outside of the organization which is providing the payment for the health care services. For the individualswho are not within the organization that is providing the payment for the health care services, the processing of the claims is frequently the aspect of the organization, especially to the health care proving community. The government agencies and administrators of the health care organization perceive the claim as the origin of information which enables the payers to evaluate and improve the organization’s production and enhance the health care of the members. The conventional claims capacity continues being in a state of evolution, the data management processes will continue creating a position of increased participation for the claims capacity of the twenty first century (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

In the review of the conventional claims capacity, the four main core competencies compose what can be considered as a claim. The core competencies incorporate information management, health care delivery service, transaction processing and quality control. Each of the main core competencies is composed of three integral elements. These elements are the peripheral implements and technology, the motivated and trained personnel, and the established communication and business processes.  The processing of the transactions is a definition which details the adjustment and the management of the health care provider claims (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

Transactional processing is the main competency of the claims process. The inability of conducting the transaction processing influences the peripheral core competencies and the organization which is providing payment. In addition to the conventional claims, numbers of managed health care organizations presently process and monitor the patients’ disease and intervention information, demographic patient information and associated data which facilitate the comprehension of the patient’s specific health results by the health care providers (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

In the event that the claims are submitted by paper of electronically, the inventory health care receipts must be assessed in order to provide sufficient resources and to confirm the economic assumptions with regards to uninsured patient populations. The other evaluations which are of great significance in the monitoring process are the following;

1. The filing of the limits within the correct time frames.
2. The turnaround period which is founded upon the date which the organization which is making the payment filed the claim.
3. The time lag incurred the claim which is the time which has passed between the date of receipt and the date of health care service (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

The INBRimplantation represents the claims which have been incurred but have not been reported. These claims are assessed by the comparison of the outstanding authorization documents which provided the authorization for the health care procedures and other visits which have goneunreported. The claims which are classified as INBR (incurred but without having been reported) are claims which were unreported due to the lack of temporal administration by the managed health care organizations (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012; Manchikanti & Hirsch, 2012).

The most significant of these evaluations is the turnaround time. The turnaround time must be created in a manner which facilitates compliance with the turnaround requisites which are administrated by the considerations of the health care provider contractual agreements of the government regulations. The less extensive turnaround objectives are often set for the claims which have been electronically submitted. . In the event that the health care providers do not fulfill the turnaround time for the claims, there may be implications for the customer service personnel in addition to incurring fines and penalties (Burkhauser et al., 2011; Foster et al., 2011; Kongsveldt, 2012;Manchikanti & Hirsch, 2012).

Conclusion

The Patient Protection and Health Care Act of 2010 has the requisite of complex processes of communication and business explanations. The information has the requirement of being visible, complete and integrated. The processes must flow from one into another in a complete sequence of events which provides for the implementation of contingency actions.  The first commercial processes initiate with the explanation to the health care providing organizations on the manner that the claims should be filed.  Over the past  several years, the explanations which have been given to health care providers with regards to the filing of claims has evolved into becoming a more intricate  and more particular process in the context of the standardized claim documents and the necessary data components.

References

Burkhauser, R.V., Lyons, S. & Simons, K. (2011). The Importance of the Meaning and Measurement of “Affordable” in the Affordable Care Act. (No. w17279) National Bureau of Economic Research.

Foster, R.S., Actuary, F. C., Pitts, C. & Palone, R. (2011). The Estimated effect of the   Affordable Health Care Act on Medicare and Medicaid Outlays and the Total   National Health Care Expenditures. Testimony before the House Committee on the Budget, January 26, 2011.

Kongstvedt, P. R. (2012). Essentials of managed health care. Jones and Bartlett Publishers.

Manchikanti, L., & Hirsch, J. A. (2012). Patient Protection and Affordable Care Act of 2010: a primer for neurointerventionalists. Journal of Neurointerventional Surgery,    4(2): 141- 146.