Safeguarding the health of Americans is one of the policy objectives that the US government pursues aggressively. The government is committed to ensuring that Americans enjoy access to affordable and quality care. The Centers for Medicare and Medicaid Services (CMS) are among the institutions that the government partners with to promote the health of Americans. The CMS releases guidelines and rules that medical practitioners are supposed to adhere to in their effort to deliver quality care to patients (“Linking Quality to Payment”, n.d). In this report, the role that CMS regulations play in defining the revenue structure of a healthcare provider is examined.
CMS involvement in reimbursement
The CMS has a wide mandate. However, it has chosen to focus on reimbursement as it seeks to promote quality standards in the healthcare industry. The Affordable Care Act is primarily responsible for the decision by CMS to become involved in reimbursement (“Affordable Care Act”, n.d). The main aim of this act is to enhance the delivery of quality and affordable care to Americans. The act seeks to ensure that no American is denied medical insurance on such ground as that they are too sick. The CMS is charged with the mandate of ensuring that the provisions of the act are enforced. Rewarding physicians and medical facilities for the provision of quality services is among the hallmarks of the act (Murdock, 2012). As one examines the provisions of the act, they are able to understand why the CMS has focused on reimbursement.
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Impact on reimbursement model
As CMS became more involved in the reimbursement component of healthcare, healthcare providers were forced to redefine their reimbursement models. As already mentioned, the Affordable Care Act set the stage for the involvement of the CMS in reimbursement. Before this act came into force, most healthcare providers placed focus on quantity over quality. This means that hospitals were not deeply concerned about improving patient outcomes. As the CMS began enforcing the provisions of the act, healthcare providers placed their focus on quality (“Nearly 12 Million”, 2013). The Affordable Care Act rewards physicians and facilities for the quality of care provided and for cutting down on costs. Therefore, to benefit from the renewed interest by the CMS in reimbursement, the Healing Hands Hospital must overhaul its reimbursement model and focus its attention on quality and cost minimization.
Effect of changes in reimbursement regulations
In addition to the Affordable Care Act, the CMS also enforces the Medicare Access & Chip Reauthorization Act (MACRA). Each of these laws introduces new regulations that impact reimbursement. For example, one of the features of MACRA is that physicians are rewarded for the value and quality of services instead of volume (“The Medicare Access”, n.d). As already mentioned, previously, facilities placed too much focus on volume to reap maximum benefit. The changes in reimbursement regulations have forced healthcare providers to abandon reimbursement policies that are inconsistent with the new regulations and adopt new ones. It can therefore be expected that new changes will force healthcare organizations to change their reimbursement policies.
Tools to ensure compliance with policies and reimbursement regulations
Organizations usually face challenges in their efforts to adopt change. There are a number of tools that such organizations as Healing Hands Hospital can implement to comply with the CMS policies and regulations. Collaboration with other Affordable Care Organizations (ACOs) is among these tools. ACOs refer to groups of physicians who join forces to deliver quality and affordable care to patients covered under Medicaid and Medicare (“Accountable Care Organization”, 2015). These physicians are rewarded for their effort. Another tool that an organization such as Healing Hands Hospital can implement is establishing internal control mechanisms. The main focus of the policies and regulations that the CMS set forth is quality and value. To comply with the policies and regulations, healthcare providers will need to conduct self-assessments to ensure that the quality of the care that they provide is in line with the standards stipulated by the CMS. Manuals, code sets and relevant acts are some of the tools that a healthcare provider can derive benefit from. The manuals concern a number of issues such as reimbursement. An organization that wishes to comply with the reimbursement regulations would benefit from studying the manuals. The code sets refer the standard codes for various illnesses and the corresponding classification. This code sets are useful in determining the amount of reimbursement that the organization can expect for attending to patients with particular illnesses. The CMS also provides links to various acts that are related to reimbursement. The Affordable Care Act is among these. As an organization examines this and other relevant acts, it is able to understand its mandate and the measures that it can implement to ensure compliance.
In conclusion, the United States is making progress in improving the quality of medical services that are delivered to its citizens. Such laws as MACRA and the Affordable Care Act should receive credit for the progress. These laws contain provisions that are redefining such issues are reimbursement. In an effort to promote quality care, the laws are promising higher returns to practitioners and facilities that focus on quality and value. Given that some success is already being witnessed, it can be expected that greater improvement will occur as more facilities embrace the new reimbursement models.
Accountable Care Organizations (ACO). (2015). Retrieved 13 th April 2017 from
Affordable Care Act in Action at CMS. (n.d). Retrieved 13 th April 2017 from
Linking Quality to Payment. (n.d). Retrieved 13 th April 2017 from
Murdock, K. (2012). Affordable Care Act. Munchen: GRIN Verlag.
Nearly 12 Million People with Medicare have Saved $26 Billion on Prescription Drugs
Since 2010. Retrieved 13 th April 2017 from
The Medicare Access & CHIP Reauthorization Act. (n.d). Retrieved 13 th April 2017 from