Case Study Analysis and Recommendations †MyAssignmenthelp.com

Question: Discuss about the Case Study Analysis and Recommendations. Answer: Introduction The Medicare Administrative Contractors in US have the task of processing an estimate of 1.2 billion worth of medical claims for beneficiaries of Medicare medical services, who are the beneficiaries of Medicare programs. With this huge backlog of cases facing them, there are huge pending appeals. This has seen the US department of health and human services strengthening the Medicare program process in an aim to combat the payment process and protect the beneficiaries. However despite this, challenge still remains large in dispensing of administrative justice and process of claims for the beneficiaries. The administration of appeals process is based on a five tier system where according to reports by GAO, (2018), through the fiscal year 2010 and 2014, saw variations in appeals request pending for processing. High degree of appeals was observed in level three which it rose from 41,733 in 2010 to a record over 880,000 in financial year 2015, while other huge chunk of appeals was notices on those filed by hospitals and inpatient stays leading to rise from 12,938 in the year 2010 to a record high of 275,791 appeals in 2014. While at the council at the end of financial year 2015, pending appeals were over 14,000, (HHS, online 2018). Critical assessments by GAO showed that there is increased number of appeals in the process being field after appeal timeframes with many appeals being significant at level 3 and 4 systems. In the financial year 2015, there is an estimate of over 1.2 billion dollars Medicare claims being processed. In the early stages of determination, there was a total of 123 million claims being denied, while of this 3.7 million claims were appealed. This signifies the threat of the problem which is going out of hand. HHS has employed varied strategies with an aim of speeding the appeals process, (Medicaid, 2018). HHS has used three strategies which include investing in new resources at all the five levels of appeal, initiating administrative functions on pending appeals and adjudicating for legislative reforms for more funding allocation and new devolved authorities to process appeals volume. However with this strategy, there is limited view of on expansion of work load to lower manageable levels. HHS management still understaffed hence dealing with huge cases remains an uphill task. Further there has been a huge beneficiary of the program making HHS unable to make fasters process to implement and adapt to the rising beneficiaries number. Lastly the management has failed to initiate favorable rules and polices regarding medical coverage and payment procedures on the beneficiary making the process stringent and time consuming, (Keith, online). The management has failed to mobilize the adjudication capacity framework through the congress to lobby for more funding allocations. There has been lit tle progress and stagnation despite the rise of beneficiaries. Further from the strategies above, CMS and HHS has developed a data sharing platform which is collected from three identified appeal systems which entail date of appeal, type of service and length of stay of appeal. However there is variations as not all agencies dealing with the appeals are data connected to share this information across the board. This has led to poor process of recoding appeals decisions in the three systems levels. There is absence of consistent appeal information, HHS monitoring capacity on emerging trends and the federal systems which is not in line with federal requirements on internal control standards and control operations for provision of relevant, reliable and timely information, (GAO, 2016). Despite of various actions of processing the back log of cases such as portion payouts waived, the backlog appeals continues to increase at a speed which the adjudication process available. This is due to the process which the appeals are, because of their repetitive nature occasioned by inefficiency process, many of the used standards do not conform to federal internal control standards, which lead to more appeals heading to appeals process, (HHS, 2018). The current review has observed that office of Medicare Hearing and Appeals adjudicators face stiff challenges in processing the medical claims. The limited human resource at this unit is crippling the activities in the appeals chamber. The HHS gave out a proposed law which is aimed at reducing the effects of the medical appeals, with key focus being expansion of OMHA, which has struggled over the past years in meeting the required work forces to process the and hear appeals. However rules 42 U.S.C. 1395f require a 90 day timeframe for adjudication by the administrative law judges, many Medicare providers are waiting for couple of years before being their appeal is heard. The Medicare has laid blamed on the recovery audit recovery team as the main source of appeals prevalence. The ALJ, has the ability to adjudicate an average of 77, 000 appeals per year despite the huge number of 800,000 pending number of appeals with expected rise in the coming years. Recommendations In order to address these challenges, this review proposes the following recommendations; Data sharing is key essence in health care organizations. HHS and CMS need to incorporate technology to process and digitize the process for enhanced efficient among the staff and overall organization framework. Partnering with internet based providers to provide internet based digitization process is essential in storing evidence reports and sharing of information for faster processing of information and reduces the back log, (Garg Tadj, 2018). Further adoption of flexible payout schemes to Medicare providers is key in reducing the appeal rate. Enabling efficient processes from filing the appeal towards hearing stage need to be flexible. Allowing cost reimbursement for Medicare agencies and streamlining the processes involved is key in ensuring Also there is need for adoption of better contractual terms and approaches to handle services such as those being handled by recovery agency, since it is attributed to cause many of the backlog due to wait time processes. Thus the management need to adopt to new and use efficient contradicting models which saves on time and process. Medicare providers tagging is key in ensuring that no multiple appeals are filed repeatedly severally. Thus this will be crucial in monitoring and regulating the rate at which providers claim medical service rendered. Proper documentation process being filed by the providers will facilitate the filing process of the cases and minimize appeals. Conclusion With numerous challenges facing CMS and HHS, it is essential for adoption of effective process which seeks to improve service delivery. Frustration which the providers face during medical appeal process is prevalent, with high observations being noticed in audit reviews section, targeting the pre-payment variety. The Medicare appeals being faced currently have shown to disadvantage Medicare providers whose cash flows are significantly lowered making the organizations activities to be paralyzed. There is need for timely hearing on appeals to providers. Adoption of technology to facilitate the process is essential. Further improvement of payment schemes for providers which are flexible is essential so as to reduce the current backload, (Rochefort, 2018). With the view of facilitating payments for easing the appeals volume care neds to be undertaken on the nature of claims, as such improper medical claims could be processed in the guise of reducing the volume. Mobilizing of the resource s need to be tracked through the federal and legislative arm for more resource allocation through mobilizing through the key relevant authorities in the health sector to manage the process, (Lind et al, 2015). Thus the highlighted recommendation forms the basis for change process in reducing the back log of appeals facing CMS and HHS. References GAO, (2018). Opportunities Remain to Improve Appeals Process - GAO .Retrieved from https://www.gao.gov/assets/680/677034.pd Garg, A. K., Tadj, L. (2018). Emerging Challenges in Business, Optimization, Technology, and Industry. HHS, (2018). FY 2017 Budget in Brief - CMS - Medicare | HHS.gov .Retrieved from https://www.hhs.gov/about/budget/fy2017/budget-in-brief/cms/medicare/index.html Lind, K. D., Noel-Miller, C. M., Zhao, L., Schur, C. (2015). Observation status: Financial implications for Medicare beneficiaries. Washington, DC: AARP Public Policy Institute, 1-24. Medicaid, (2018). DEPARTMENT OF HEALTH HUMAN SERVICES Centers ... - Medicaid .Retrieved from https://www.medicaid.gov/.../financial_models_supporting_integrated_care_smd.pdf Medicare, (2018). Medicare Parts A B Appeals Process - CMS.gov ac. Retrieved from https://www.cms.gov/Outreach and.../Medicare...MLN/.../MedicareAppealsprocess.pdf Rochefort, D. A. (2018). The Affordable Care Act and the Faltering Revolution in Behavioral Health Care. International Journal of Health Services, 0020731417753674.