1

Federal Government Payer Program – Medicare

Student Name

Institution Affiliation

Course Name

Professor Name

Date
 2

Federal Government Payer Program – Medicare

Medicare is a federal government payer program created in 1965 to assist people above

65 years, those with end-stage renal disease, and certain younger people with disabilities get

private health insurance coverage. Its sole purpose was to help improve the health and longevity

of older Americans regardless of their income and medical history. Medicare is categorized into

parts A, B, C, and D to help cover specific services that are offered by insurance companies that

are approved by Medicare. Medicare strives to offer efficient, safe, effective, equitable, timely,

and patient-centered healthcare services. To enable it to achieve these goals, Medicare ensures

that health care institutions and physicians meet licensure, certification, or accreditation

standards before they are approved to provide services to Americans.

Licensing refers to a process of granting permission to health care organizations or

individual practitioners by ensuring they meet minimum standards set to protect public health

and safety. This may either be done through an on-site inspection for organizations or through

some form of examination to prove professional competence. Health care organizations and

individual practitioners are licensed if they met the minimum standards. Accreditation, on the

other hand, is a comprehensive evaluation process done by accrediting organizations to health

care institution’s governance and operations to ensure they meet predetermined criteria and are

consistent with state and national standards. Medicare is keen to work with health care

institutions and individual practitioners that meet licensure and accreditation standards. For

instance, Centers for Medicare and Medicaid Services (CMS) impacts the above standards by

ensuring that suppliers participate in competitive bidding programs for all Medicare Durable

Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS). To be awarded a contract,

the supplier must have the required state licenses and meet all DMEPOS state licensure
 3

requirements (Ji, 2019). Additionally, the supplier must be accredited by a CMS-approved

accrediting organization for the items in a product category. Therefore, any organization with an

intent to conduct business with CMS, including healthcare institutions, must be licensed by the

state and accredited by a CMS accrediting organization to ensure patient services are efficient,

timely, safe, and patient-centered.

The Centers for Medicare & Medicaid Services (CMS) is committed to improving

quality, affordability, and accessibility of healthcare for all Americans. In CMS, quality

healthcare is given the highest priority and is defined as having properties such as equity,

effectiveness, efficiency, timeliness, safety, and patient-centered. As a result, quality reporting is

an important element and a CMS requirement for all healthcare institutions as it helps guide

quality and performance improvement efforts. For instance, CMS requires health home agencies

to collect and report performance data using a data collection tool known as the Outcome and

Assessment Information Set (OASIS). Recently, CMS updated the OASIS data set to AOSIS-D

to ease home agencies reporting. Quality reporting may also be done on the Medicare.gov

website, where a star rating was introduced to motivate home health agencies to report

performance data.

Haglin et al. defines Medicare reimbursement as the payment that healthcare providers,

suppliers, and physicians receive as compensation for healthcare services rendered to Medicare

beneficiaries (Haglin et al., 2020). Reimbursement for healthcare services at Medicare is done

based on Medicare plans, that is Part A, B, C and part D. for part A and B, Medicare providers

and suppliers send claims directly to Medicare without individuals receiving a bill. However,

depending on whether healthcare providers are participating or non-participating providers, an

individual may be required to pay coinsurance and deductibles. In some instances, an individual
 4

may be required to pay upfront for services and later file a Medicare claim for reimbursement. In

this case, the claim should be filed within a year from the date of service. Instructions should be

followed strictly while filling the Patient Request for Medical Payment Form. If the claim is

accepted, the reimbursement process begins.

Medicare has made it possible for beneficiaries to enjoy broad access to physicians and

hospitals. Many beneficiaries can obtain care when needed, easily find new physicians, schedule

timely appointments, and, most importantly, have a source of care. However, a small number of

low-income Medicare beneficiaries report some challenges with accessing healthcare or delayed

care due to a lack of finances that limit them from seeing a doctor or taking the recommended

medical tests. Many beneficiaries report that improvements made by Medicare have improved

access to care for older adults and people with disabilities as opposed to those not covered by

Medicare.

Health Information Management (HIM) is the process of collecting, analyzing, and

protecting health information with the aim of providing quality health care (Zeng et al., 2009).

The most important role of a HIM professional is to ensure quality, integrity, and protection of

patient’s health information. This aligns with Medicare’s goal of providing quality healthcare for

all. A HIM professional will ensure that patient information under Medicare coverage is well

protected and available when needed. The availability of the patient data in quality reporting

gives a better picture of whether the patient is receiving better care or not and provide areas that

need improvement under Medicare.

References

Haglin, J. M., Eltorai, A. E., Richter, K. R., Jogerst, K., & Daniels, A. H. (2020). Medicare

reimbursement for general surgery procedures: 2000 to 2018. Annals of Surgery, 271(1),

17-22.

Ji, Y. (2019). The Impact of Competitive Bidding in Health Care: The Case of Medicare Durable

Medical Equipment.

Zeng, X., Reynolds, R., & Sharp, M. (2009). Redefining the roles of health information

management professionals in health information technology. Perspectives in Health

Information Management/AHIMA, American Health Information Management

Association, 6(Summer).