Question

B) Describe, define and explain the methodologies used by both Medicare and Medicaid to pay providers for the following services:

1) hospital in-patient services,

2) physician professional services.

3) out-patient medical services and tests (lab, x-ray, etc.).

Answer 1

Medicare: it is a federal program that provides health coverage if the patients are 65 and older or have a severe disability, no matter the income.

Medicaid: it is a state and federal program that provides health coverage if the patient have a very low income.

1. A. According to Medicare the methodology used for hospital in-Patient services including semi-private rooms, meals, general nursing, drugs as part of inpatient treatment and other hospital services and supplies.

B. According to Medicaid the methodology used for hospital inpatient services includes generalized for purposes like cost based payment, prospective payment, per diem, per discharge, percentage of charge. Additionally some states establish their rates on a hospital-specific basis, while other group hospitals with their peers and set rates geographically. Other states adjust rates of reimbursement based on hospital occupancy levels.

2. A. Physician professional services in Medicare includes those paid under or based on the Medicare physician fee schedule. To extent that eligible professionals are providing services which get paid u see or based on the PFS. The services includes office visits, surgical procedures and diagnostic and therapeutic services in a variety of settings.

B. Physician professional services in Medicaid covered services including those of a physician, nurse midwife, nurse practitioner, clinical nurse specialists, physician assistant, audiologist. Immunizations are covered for recipients under age 21. Certain family planning services are covered when provided in a physician's office.

3. A. Out patients medical services in Medicare covers medically necessary diagnostic and treatment services that get as an out patient from a Medicare participating hospital.

• Covered services includes emergency or observation services which may include an overnight stay in the hospital.
• Services in an outpatient clinic including same day surgery.
• Lab test billed by the hospital.
• Mental health care in a patient hospitalization program if a doctor certifies that inpatient treatment would be required without it.
• X- ray and other radiology services billed by the hospital.
• Medical supplies like splints and casts.
• Preventive and screening services.

B. Out patient medical services in Medicaid covered medically necessary preventative, diagnostic, rehabilitative or palliative items or services.

• Maternity stay like abortions.
• Dental services
• End stage renal disease services
• Out patient surgery like sterilization .