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Medicare Program: Reporting, Services, and Reimbursement

Federal Government Pay: Medicare

Medicare significantly impacts the certification, accreditation, or licensure standards of the healthcare facilities and organizations associated with them since Medicare expects such hospitals to meet specific criteria to qualify for the deemed status. The center for Medicare and Medicaid Services (CMS) sets the criteria mentioned above, and these guidelines are referred to as the Conditions for Participation. According to CMS (2021), the organization develops the Conditions of Participation (CoPs) and Conditions for Coverage (CfCs) that health facilities meet to start and continue their participation in the Medicare and Medicaid program. The Conditions for Participation are 24 and are further divided into 75 standards. Every healthcare organization that seeks Medicare deemed status must meet all the 75 standards. CMS (2021) reveals that it ensures strict adherence to the Medicare standards making health facilities attain the deemed status as set in Medicare’s CoPs and CfCs. The facilities that meet the mentioned standards are then accredited by the American Osteopathic Association (AOA), enabling healthcare providers to participate in Medicare.

Clinical quality reporting systems

Medicare has significant impacts on clinical quality reporting systems since it requires healthcare facilities to submit reports regarding their clinical quality measures mostly using digital platforms. Medicare uses the data submitted by healthcare providers to measure the facilities’ healthcare quality. The measurements and reports submitted electronically ensure that the healthcare system delivers care that is safe, timely, efficient, patient-centered, and efficient. For instance, individual medics and health facilities are required to submit reports on patient safety, clinical processes, patient engagement, care coordination, and resource utilization efficiency. Consequently, Medicare requires hospitals and doctors to electronically report eCOMs, using the data obtained from electronic health records or other systems of health information technology used by the participating health organizations. Successful eCOMs reports are those that adhere to the standards set by the CMS quality programs in specific areas where the healthcare providers are participants (CMS, 2021). Therefore, these processes show how Medicare impacts clinical quality reporting systems of healthcare organizations seeking to participate in Medicare programs.

Reimbursement for healthcare services

Medicare uses the Prospective Payment System (PPS) to reimburse healthcare services. CMS (2021) defines a Prospective Payment System as Medicare payments that comprise fixed amounts predetermined by any participating organization. The reimbursements are further classified into different groups, such as the Diagnostic Related Groups (DRGs), which is when patients are classified based on their specific diagnosis. Consequently, Medicare has a pre-determined amount it reimburses to a patient falling under any set DGR. CMS (2021) reveals that CMS utilizes other PPSs, especially in reimbursing inpatients who have acute cases. The CMS also uses different PPSs for home health providers, hospitals offering outpatient services, hospices, and facilities offering inpatient psychiatry. The PPSs are also applied in inpatient rehabilitation and long-term care hospitals, and skilled caregiving facilities.

Patient access to care

Medicare influences patient access to care in different ways based on the plan and facilities selected by the sick. The Center for Disease Control and Prevention (CDC) reveals that the National Ambulatory Medical Care Survey (NAMCS) federal survey analysis indicated that the proportion of medics that accepts new Medicare subscribers has remained stable for years. This reveals that facilities are not admitting more users or maintaining a limit of new entrants to their systems. The trend shows that Medicare affects patient access to care in similar ways as existing private insurance providers. In most cases, the insurance providers also have several limits, which affect the number of people subscribing to such care plans. The difference is mainly in the approach of giving the care plans, though the effects are the same on the clients. The CDC (2021) further indicates that above ninety percent of the physicians that were surveyed reported admitting new Medicare patients in equal numbers, making the trend stable for over seven years. The outcome of the report demonstrates that Medicare has a significant influence on patient access to care, and this impact has been positive over the admission period.

Medicare’s influence on patient access to care can also be understood based on the organization’s approach to data collection and processing. Medicare advocates using the Uniform Hospital Discharge Data Set (UHDDS) as its primary data collection method since the UHDDS helps it collect uniform data elements of all the health facilities offering inpatient services. Critical information, including principal diagnosis and principal procedure included in such data. Moreover, the UHDDS are considered components of DRGs, making it easy for Medicare to calculate the pre-set reimbursements for any DGR. Medicare also uses a Minimum Data Set (MDS), which is a federal standard form of assessment that the organization uses to gather information such as demographic and clinical data of those receiving nursing care in their homes. The form enables the patients to complete the required information before they can be admitted or reassessed for the care plans they can qualify to subscribe to in the various Medicare care levels. MDS is crucial in collecting data used to categorize Medicare residents based on their Resource Utilization Groups (RUGS).

Medical reimbursement

Medical reimbursement specialists are experts within the medical administrative levels tasked with submitting and processing various medical claims that patients put on their registered insurance providers on behalf of the healthcare facilities. The medical reimbursement officer is therefore meant to work with Medicare to submit insurance claims for the various services that a given healthcare facility has rendered a registered patient. During the work, such a specialist is tasked with ensuring that the data submitted is accurate and complete and that the information is available to the payment processor in time, thus preventing delays and possible reimbursement claim denials.

A medical reimbursement specialist is also responsible for ensuring that the insurance claimant follows specific Medicare guidelines related to the conditions to which the patient is subject. The reimbursement specialist must ensure that such conditions are met before submitting the claim, as any slight deviations can result in the denial of payments or can result in unnecessary delays. However, such cases can be affected by several factors, including errors made by the claimants. Thus, the specialist can help where possible to avert future errors in the insurance claim process. Some of the areas that the medical reimbursement specialist must check to ensure conformity include the eligibility of the patient submitting the claim. There are set guidelines that show who is eligible for any given Medicare plan. After verifying the eligibility of the patient, the medical reimbursement specialist must understand the codes associated with the claim made by the patient and then check its accuracy against the standards set by Medicare. Other areas that the specialist must check to include noting the fee schedules, ensuring complete information is available as provided by Medicare, and being sensitive to the method of submitting the final forms.


Center for Disease Control and Prevention (CDC). (2021). Survey Results and Products. Web.

U.S. Centers for Medicare & Medicaid (CMS). (2021). Medicare. Web.

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"Medicare Program: Reporting, Services, and Reimbursement." ApeGrade, 2 Dec. 2022, apegrade.com/medicare-program-reporting-services-and-reimbursement/.

1. ApeGrade. "Medicare Program: Reporting, Services, and Reimbursement." December 2, 2022. https://apegrade.com/medicare-program-reporting-services-and-reimbursement/.


ApeGrade. "Medicare Program: Reporting, Services, and Reimbursement." December 2, 2022. https://apegrade.com/medicare-program-reporting-services-and-reimbursement/.


ApeGrade. 2022. "Medicare Program: Reporting, Services, and Reimbursement." December 2, 2022. https://apegrade.com/medicare-program-reporting-services-and-reimbursement/.


ApeGrade. (2022) 'Medicare Program: Reporting, Services, and Reimbursement'. 2 December.

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