Judicial Adoptions To Single Agency Of State Term Paper

Type of paper: Term Paper

Topic: Compensation, Nursing, Medicare, Medicine, Government, Politics, Services, Money

Pages: 8

Words: 2200

Published: 2021/01/04

Issues in Medicare/Medicaid Reimbursement

The paper is aimed at researching about the Medicare / Medicaid reimbursement issues. The paper starts with a brief introduction of the topic while highlighting major aspects of the challenges faced by patients and medical institutions/physicians. There are several aspects and domains in medical re-imbursement which merit attention and are covered in this paper. After the introduction to the topic, the paper proceeds to presenting literature review of important researches done on the topic. The literature review also covers the major issues in Medicare / Medicaid reimbursement while highlighting various levels including issues faced by patients, medical institutions and physicians. Subsequent to the literature review, the paper proceeds to the analysis of the issues while highlighting important statistics on the subject. The paper proceeds to integrating the major issues while interpreting them in an effective manner. The paper ends with a brief conclusion which also suggests improvement in the Medicare / Medicaid reimbursement system.


The term reimbursement refers to the payment made by the insurance companies to the physicians who provide medical services. The commitment level of physicians directly affects not only them but also the patients entitled to receive medical treatment from them. It is important to realize that satisfaction or stress level of physicians have profound impact on the quality of service, safety of patient, time they give to patient and most importantly the availability or easy access to professional and skilled physicians. Therefore it is highly imperative to understand these factors and to take suitable measures to solve the issues caused by these factors in an effective manner .

Literature Review

According to a research specially designed surveys have been conducted to better understand the issues related to reimbursement and to improve the quality of health care facilities. However, it is essential to understand that if efforts are being made in improvising the 1% of reimbursement made by government, it will ultimately shift the focus from improving the quality of health care facilities for patients to patient perception manipulation. Government has launched a new policy under which institutes will be reimbursed based on the satisfaction level of the patients. This has shifted the focus from the core nursing objectives to measuring and mandating compassion. Empathy, compassion and kindness are the fundamental elements of nursing and they can be regulated by the nursing staff. However there are other unavoidable situations which are beyond the control of nursing staff. But according to the recent policy the institute and the nursing staff members will be held accountable for the satisfaction level of patients regardless of other uncontrollable variables .
According to another research a central issue that needs to be addressed on immediate basis in reimbursement is to validate the efficacy and proficiency of the contractors. Government is increasingly emphasizing on the post-payment assessments of contractors to ensure their effectiveness. It has been reported that contractors pose huge influence on the review in order to manipulate the payments .
According to Medicaid policy there is a list of drugs which are entitled to be reimbursed by the government. However, it has been reported that there are few drugs which are not on the list and if prescribed by the physician then patients are not reimbursed. There are few drugs which are clinically prescribed by physicians in few states but not in other. Under this situation the concerned government bodies should either amend the list of drugs or review this list time to time. However, there are few other solutions to this problem such as, the list of drugs entitled to be reimbursed may vary from state to state or the individual case of patient may be taken into consideration for any drug that is not on the list of federal government. Such changes in the government policies will greatly facilitate the patients in getting proper treatment and reimbursement .
There is a number of frauds and other issues that are faced by the patients as well as the medical institutions in getting their rightful reimbursements. There are frauds committed by people to the government regarding getting reimbursed on the Medicare / Medicaid for which they are not entitled. Such frauds not only bring burden on the budget of government but also put the rightful people in doubt. Government regularly reviews policies of reimbursement in order to counter fraudulent attempts; however, such policies comes at a price to the individuals who are deserving for the reimbursement. They have to go through a lengthy procedure in order to get the reimbursement which causes an increased level of stress to them especially in the case of elderly people. There is a number of abuses that are also present in the system of Medicare / Medicaid reimbursement. Such abuses include attempts to conduct activities that are not in line with the defined set of procedures for the medical services. These include using the medical equipment or giving medical service to people who are entitled to it or giving cheaper medicine to the patient then the one prescribed by the physician .


The issues highlighted in the literature review above are not the only issues in Medicare / Medicaid reimbursement. These are the major ones that were found in scholarly peer-reviewed source. There is a number of other issues in the field which also merit attention. A brief analysis of the issues presented in the literature review part and other associated issues are presented in subsequent paragraphs. This part also covers important statistics related to the Medicare / Medicaid reimbursement.
Usual family practice examination shows that a family physician (FP) earns around USD 189,000 on average per year that is quite less as compared to usual orthopedic surgeon’s earnings. Typical overhead of FP consists of around 60% of gross practice income (that is nearly USD 472,000). By substituting the medical repayment rates for viable insurance-related payments, the gross income of FP becomes USD 420,000 on average. When overhead is paid, then the total FP income becomes USD 137,000. Such income level will not ruin the medical practice in general. However, unlike the case of specialist physicians who, despite having payment cuts, will be still earning nearly 0.5 million dollars through all Medicare and Medicaid services. The general physicians having further repayment reductions in their income will face lots of challenges, especially considering their long working hours, educational loans, and new infrastructure cost demands. The argument about bankrupting the practice further deductions of Medicare and Medicaid made by primary care physicians is more convincing. Hence high repayment is required by these physicians to achieve their worthy target of evolving medical homes from their practices and efforts to carry out payment reforms to meet their needs. However, the awaiting bankruptcy claims made by specialist physicians, such as orthopedic surgeons are just mere speechmaking. It’s purely a choice for specialists to either treat or not patients of Medicare and Medicaid reflecting their priorities. They use this choice to wrap the survival needs in their wrong and confusing speechmaking .
A suitable approach is reorganizing the inconsistent PFS by cutting the connection between GDP, PFS and SGR. Because this connection permits CMS to establish some “expenses target” regarding all medical services, which leads to an uneven payment system and they also find an excuse for making sharp reimbursement reductions. Specialty Medicine Alliance along with the AAOS are in favor of plans like Medical Economic Index (MEI) which are centered on price of care provision facility. SGR is made collectively, comparing the collective expense targets with collective expense cost, rather comparing total expense target per year with actual costs during the year. According to this method in order to maintain stability in a system and to allow annual changes in services, the extra expenses should be recovered on immediate basis. Moreover the idea of new technology use, its cost implications and savings leading to overall variation in services, having improved screening methods and consumer’s awareness of this idea and demanding it is not currently present in the system. Eventually the target is to include those outpatient medicines that are covered by Medicare though the costs of such medicines are not much controlled by physicians .

Inter-government transmissions (IGTs)
Certified public expenses (CPEs)
Allowable taxes and donations by provider
Before approval of any amendments in state plan by CMS, it must be ensured that funding sources of state are meeting the constitutional and controlling needs so that they are able to allow FFP (financial federal participation) for provided services .


The supplier’s challenge to national reimbursement tariff plan may be based on technical applicable grounds. Under an effective legal challenge, the general claim is made regarding defiance of state or national plan with central “ rational and adequate” criteria standard and also relating to procedural defiance ( like absence of public notices, inability to submit sufficient pledges). Claims appealing the Clause of Equal Protection often follow a complaint or objection of dissimilar treatment on the basis of social welfare or economic classification. The laws of equality of state plan are endorsed on common basis to promote the genuine interest of state in monitoring the charges or rates by Medicaid contributing homes to private reimbursing residents. This equality protection claim is not possible to succeed under these type of laws, unless it is boosted by reflecting a decrease trend in patient care quality measures or access to medical services. For the success of procedural claims that are founded on insufficient amount of pledges or conclusions it is necessary to show that the pledges or assurances made by state were based on intentional unfair data interpretation or on inadequate conclusions or findings.
It is anticipated from the recent decisions that while dealing with state assurances the courts will be opting for stricter review than past years. The attacks which were targeted against reducing isolated component belonging to the rate have not been much fruitful. The courts imposed a resolution related to rate “rationality and sufficiency” on overall repayment rather than imposing it on its isolated components. According to tenth circuit decision, state agencies may depend on budget limitations in formulating rates of payment but they don’t provide enough basis to make amendments in an existing plan, to apply some new plan or to draw mandatory conclusions on annual basis. Even though federal circuits convenes providers with the litigation right against state officials under 1983 U.S.C. Section 42, future decision by Supreme Court is needed to determine that if provider has personal right of imposing reimbursement necessities in federal court under Boren Amendment. States are so far unsuccessful in challenging it and they are hopeful to get bail from Supreme Court with opposite ruling for the providers .


Reimbursement issues are present at many levels. The terms and conditions of the insurance contract can be tricky in such a manner that a patient is unable to find out the catch in it and ends up getting deprived of the reimbursement. Medical institutions and physicians are reimbursed on the basis of the services they provide to the patients. A number of issues pertaining to Medicare / Medicaid reimbursement have been identified in this paper while covering major aspects of each. Government needs to implement effective policies in order to ensure transparent reimbursement of Medicare / Medicaid which would not only ensure reimbursement to the deserving ones but it will also reduce the burden from the government which are presently existing through improper payments to the service providers.


Adamopoulos, H. (2014, August 14). GAO identifies ways to fix Medicare audits. Retrieved from http://www.beckershospitalreview.com: http://www.beckershospitalreview.com/finance/gao-identifies-ways-to-fix-medicare-audits.html
Bailes, J. S. (1995). Current Issues in Oncology Reimbursement. Oncology Journal.
Financing & Reimbursement. (n.d.). Retrieved from http://www.medicaid.gov: http://www.medicaid.gov/medicaid-chip-program-information/by-topics/financing-and-reimbursement/financing-and-reimbursement.html
Geiger, N. F. (2012). On Tying Medicare Reimbursement to Patient Satisfaction Surveys. American Journal of Nursing, 11.
Naglak, D. M. (1990). Medicare/Medicaid Reimbursement Issues - A Provider's Perspective. Journal of Law and Health, 79-98.
Ranawat, A., & Nunley, R. M. (2015). Issues Facing America: Medicare. AAOS Now.
Reimbursement, Physician Fees - What it all Means for Patients and Ethical Partnership. (n.d.). Retrieved from http://www.ethicalhealthpartnerships.org: http://www.ethicalhealthpartnerships.org/reimbursement.html
Rickert, J. (2012, October 2). Do Medicare And Medicaid Payment Rates Really Threaten Physicians with Bankruptcy? Retrieved from http://healthaffairs.org: http://healthaffairs.org/blog/2012/10/02/do-medicare-and-medicaid-payment-rates-really-threaten-physicians-with-bankruptcy/
Rudman, W. J. (2009). Healthcare Fraud and Abuse. Perspect Health Inf Manag, 6.

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Judicial Adoptions To Single Agency Of State Term Paper. Free Essay Examples - WePapers.com. https://www.wepapers.com/samples/judicial-adoptions-to-single-agency-of-state-term-paper/. Published Jan 04, 2021. Accessed August 11, 2022.

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