During Week 3, I spent most of my time with the medical clinic’s billing specialist to learn more about her job and how medical insurance works. I also spent some time observing infusions of medications given for Rheumatoid arthritis and Osteoporosis in the infusion clinic.
The billing specialist first talked about PQRS, Physician Quality Reporting System, and how Medicare incentivizes or penalizes physicians based on the quality of the care provided for patients and documented by physicians. This system was put in place in 2015/2016 and will be replaced by MACRA (Medicare Access and CHIP Reauthorization Act of 2015) and MIPS (Merit-Based Incentive Payment Systems) in 2017. Because the clinic is a speciality clinic, the government assesses quality based on registry-based reporting based on certain measures. For Rheumatology, these measures include Preventive Care and BMI screening, Pain assessment and follow-up, Tuberculosis screening, Glucocorticoid Management, Assessment and Classification of Disease Prognosis. Once all the reporting is sent to the government, Medicare has a value payment modifier that provides different payments to the physicians. The differential payment is based on quality of care provided to Medicare patients through performance of PQRS measures and the cost of the care that was provided.
The billing specialist and I talked about how patients are billed through Medicare and Commercial insurance plans. I learned that Medicare usually pays 80% of the cost. We went over deductibles, copays, coinsurance, and out of pocket maximums. The deductible is how much the patient must meet out of pocket before the insurance company will begin to pay based on plan benefits. A co-pay is a flat fee assigned to various services which the patient is responsible for paying as well. Coinsurance is a percentage of the allowed amount for which the patient is responsible. Out of Pocket refers to the amount that the patient must pay before insurance will begin to pay at 100% of the cost.