Healthcare Reforms Position Paper (Essay Sample)

Healthcare Reforms Position Paper
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Healthcare Reforms
Healthy citizens are the backbone of every successful economy in the world. They provide reliable workforces which greatly contribute to the performance and productivity of various sectors of the economy. Millions of dollars are allocated and spent every year towards ensuring that the health sector is effective and productive towards meeting the medical needs of the American citizens. Various health reforms have been embraced to govern the health sector in United States. For example, in March 2010, president Obama signed two health reform legislation into law, Reconciliation Act of 2010 and the Affordable Care Act (ACA) to ensure effective and smooth working of this sensitive and important sector (Redling, 2013). This paper discusses the role of healthcare reforms, the responsibilities of medical insurance specialists, fraud and abuse and the implications of healthcare reform measures on the Medical Insurance Specialist profession.
Many health organizations in the United States have embraced and supported Obama’s administration to reform the healthcare sector. They have recognized the opportunities provided by the reforms in expanding access to high-quality health care that is cost effective and also one that lays greater emphasis on preventive and primary care in America. The signing of the two reform bills shows the realization of the goals and objectives that started in the late 1950s by the medical sector. The new reform laws provide a series of the much-needed changes in delivery of health care, coverage, education and training as well as payment for the services. Some of these changes are immediate while others require implementation in different phases over the years. The provisions in the reforms broaden and recognize the role of medical/health insurance specialists towards primary care and other health care services (Redling, 2013).
According to Stanton (2001), medical insurance specialists review patient records and accurately code all the diagnoses, services and procedures aimed at providing patients with obtaining maximum benefits. They research and pass knowledge on insurance rules, obligations and regulations in facilitating the analysis of patient base engineered towards effective and efficient operations to contain costs. Medical insurance specialists accurately post adjustment, charges, payment and other pertinent information into the patient’s database. In addition, medical insurance specialists are tasked with preparing, reviewing and remitting advice on all insurance claims and reimbursement using the necessary processes, procedures and avenues. Therefore, medical insurance specialists are involved in the logistics and administration of patients’ records, insurance benefits and play an advisory role on different policies, regulation and claims through maintaining professionalism and confidentiality of patient’s information (Redling, 2013).
Fraud and Abuse
Fraud and abuse is an economic drain to the healthcare system and costs every nation the health of its citizen. According to Morris (2009), it is estimated that only 3% to 10% of fraud and abuse is identified or reported to relevant authorities for action despite the attention and reforms initiated by United States’ government. Over the last decade, healthcare fraud and abuse has been growing fast, and many criminals are abandoning other dangerous activities in favor of the loopholes provided by this sector. It is the most essential reason for the rise in the cost of accessing proper and high-quality healthcare.
Many Americans who are unable to afford health care rely on the government for assistance through programs like Medicare and Medicaid. Therefore, it is a critical issue to the United States’ government because it is the principal payer of healthcare, and fraud and abuse in this sector is a waste of a lot of taxpayer’s money. Additionally, the U.S government is tasked with regulating the healthcare system and allowing fraud and abuse of this sector means that it has failed in its mandate. The U.S government is entrusted with protecting its citizens from fraudulent activities and criminals. This is the main reason the government is keen to allocate many funds and resources towards fraud research and investigations with much hope of identifying and fixing fraud and abuse issues in this sector (Redling, 2013).
The potential for fraud and abuse is diverse and vary depending on the nature and magnitude of the effects. The most common cases of fraud and abuse include up coding, Phantom billing, unnecessary services, double billing, bogus billing and pharmacy fraud (Stanton, 2001). Up coding involves claiming a code that legitimizes a higher reimbursement than what was actually provided. It is an easy task to accomplish but difficult to detect (Morris, 2009). Phantom billing occurs when medical insurance specialists charge for services that are not given to patients through coding a service that was not rendered and coding a procedure for non-existing patient. Double billing is also known as unbundling. It involves duplicating bills to the same or different payees and accounts for about 4% of healthcare fraud (Stanton, 2001). Bogus billing occurs when a billing code is altered to cover services that are not to be covered. Pharmacy fraud involves charging generic drugs as the original ones or higher. It also occurs when a patient is directed to buy the drugs at a chemist owned outside the confinement of a hospital where the price is usually hiked (Morris, 2009).
Cases of fraud and abuse can be prevented if necessary practices and measure are implemented. To begin with, medical insurance specialists need to be incorporated and actively involved in policy-making bodies both at the local and national levels to offer...