The healthcare industry has its own set of technical terminology that it uses on a daily basis to make communication concise while also conveying complex terms. At DECO, our goal is to help you understand the whole process even better than you already do. So we want to help you navigate through some of this information and inform you about how it can affect your healthcare organization. Here are some of the basics of what you need to know about healthcare.
Medicaid & Medicare
These two terms, which can easily be confused with one another, are some of the biggest terms in the healthcare sector. They are also two of the biggest programs that the United States government pays for. Medicaid and Medicare are the government’s answers to some of the biggest healthcare issues in this nation, and they’ve been around for decades. They are also umbrellas under which many other technical terms reside.
Medicare
Medicare is one of the largest government programs in the United States, comparable in spending to public education and Social Security. It provides subsidized healthcare to senior citizens (individuals over the age of 65) who no longer have access to it due to retirement or ineligibility for other programs. In some special cases, like middle-aged disability, an individual may be able to draw upon Medicare for medical expenses earlier than the age of 65.
Medicaid
Medicaid works in a similar fashion and is the third largest domestic government program in the United States (accounting for $577 billion in FY 2017), though it is only for individuals under the age of 65. It usually covers the low-income populations of the United States, individuals with disabilities or chronic illness, individuals who are unemployed, pregnant women, children (through CHIP, the Children’s Health Insurance Program) and several other categories of people. If your healthcare organization treats individuals who fit within these categories, it may be entitled to financial compensation from the government. This process, however, can often be long and challenging.
Affordable Care Act
Usually known as the ACA or Obamacare, the Affordable Care Act is a massive healthcare bill that was passed into law during the presidency of Barack Obama. It expanded government spending and regulations to accommodate the increasing need for financial assistance in the American healthcare system. As controversial as this law has been, and though it has changed much since most of its major provisions went into effect in 2014, it has become a mainstay of the healthcare revenue system. It has allowed the expansion of Medicaid and Medicare provision to those in the “coverage gap” (the population that has been unable to afford healthcare due to ineligibility), though both of these programs are largely determined and regulated by individual state mandates.
The Health Insurance Marketplace
The ACA also established the Healthcare Marketplace, a hub where individuals can sign up for private healthcare plans outside of Medicaid/Medicare or employer-provided healthcare programs.
Federal Poverty Level
The Federal Poverty Level, or FPL, is a metric that the ACA uses to determine eligibility for Medicaid provision. The current standard in any state that has fully implemented the regulations of the ACA is that most people whose income is less than 138 percent of the FPL can be eligible for Medicaid. The FPL currently sits at about $21,720 annually for a family of three in 2020.
Work Requirements
One of the most hotly debated topics within the sphere of the ACA is work requirements. If a state has implemented work requirements as a part of being eligible for Medicaid, it means that nonexempt recipients must be able to show that they have worked for a set number of hours per week, whether that be through a job, education, volunteer work or other form of community investment.
Social Security
Another major program of the federal government, Social Security is closely linked in many cases to Medicaid and Medicare.
Social Security Disability Insurance
Social Security Disability Insurance (SSDI) is a program that provides free or reduced-cost healthcare to individuals with disabilities. These people and their families or caretakers may be unable to work, and therefore are unlikely to be able to pay for healthcare services. SSDI can help them gain access to the care they need.
Supplemental Security Income
Supplemental Security Income (SSI) is a program designed for the most economically disadvantaged and vulnerable individuals of the nation. These individuals commonly have little to no income or resources at their disposal. Not only does SSI provide them with income to meet their most basic needs, it can also help them become eligible for Medicaid.
Revenue Cycle Management
Revenue Cycle Management is a broad term that describes the process by which a healthcare organization or hospital receives and uses funds to provide the highest quality care possible to patients. Depending on the strategy that the healthcare organization uses, its RCM can end up being simple or complex.
Billing
One aspect of RCM that can easily add a great deal of complexity and lead to a lack of resources is the billing cycle. If a hospital is unable to effectively keep track of bill payment, patients’ abilities to pay their bills or support from government programs, it may find itself floundering.
Eligibility/Eligibility Advocate
This leads to the eligibility side of the RCM system. Many patients who don’t have healthcare coverage may be eligible for financial assistance from government programs like Medicaid. However, the process to receive such support is often long and difficult to understand. The patient may have no idea where to even start finding healthcare coverage. But if an eligibility advocate or specialist can guide them through the process, help them fill out and submit the necessary paperwork and promote their health and well-being, both they and the healthcare organization that treated them can end up in a much better financial situation.
Reimbursement Models
Health insurance and reimbursement can take many different forms outside the spectrum of government-subsidized care. Some of these models include:
- Fee-for-Service Care
- Value-Based Care
- Managed Care—which includes:
- Health Maintenance Organizations
- Preferred Provider Organizations
- Point of Service Models
What DECO Does
Our specialty at DECO is getting into the middle of your healthcare organization’s revenue cycle management process and figuring out how to make it work better for you. That means visiting patients while they’re in the hospital. It means gathering patient information to help them become eligible for healthcare assistance if they don’t currently have access to it. And it means working on the front lines with billing staff to help administrative work go smoothly. Our eligibility advocates and other expert personnel are here to help your healthcare organization improve its finances and solve problems that could be costly. If your organization needs help figuring out an effective revenue cycle management system and getting compensated for care that it has provided, contact us today.
