Health Services Coordinators (HSCs) Orientation Manual
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect.
A. Provide a title page, table of contents, and chapter headings as follows for the orientation manual described in the scenario:
• Chapter 1: Medicare/Medicaid
• Chapter 2: HMO/PPO Plans
• Chapter 3: Role of the HSC
• Chapter 4: Community Resources and Programs
Chapter 1: Medicare/Medicaid
B. Discuss the Medicare reimbursement process by doing the following:
1. Describe three Medicare reimbursement requirements.
2. Describe three methods that are in place to ensure your facility remains compliant with Medicare reimbursement requirements.
3. Describe three Medicare reimbursement regulations.
C. Discuss the Medicaid reimbursement process by doing the following:
1. Describe three Medicaid reimbursement requirements.
2. Describe three methods that are in place to ensure your facility remains compliant with Medicaid reimbursement requirements.
3. Describe three Medicaid reimbursement regulations.
Chapter 2: HMO/PPO Plans
D. Choose an HMO or PPO plan, and discuss compliance regulations by doing the following:
1. Describe standard mechanisms for an appeal for denial of coverage.
2. Discuss reimbursement limitations.
Chapter 3: Role of the HSC
E. Discuss the HSC’s role across practice settings by doing the following:
1. Describe four job tasks for the HSC.
2. Describe how the job tasks from part E1 apply to working with clients at risk for each of the five domains of the SDOHs.
3. Discuss three ethical dilemmas that may be encountered in the HSC role.
a. Justify how each of the 3 examples could be considered ethical dilemmas.
Chapter 4: Community Resources and Programs
F. Discuss community resources and programs by doing the following:
1. Discuss how three existing community resources in your area could help mitigate the negative effects or enhance the positive effects of one SDOH.
2. Describe two community resources that are needed in your area to help mitigate the negative effects or enhance the positive effects of the SDOH from part F1.
a. Explain two reasons why the community resources from part F2 could mitigate the negative effects of the SDOH in your area.
b. Explain two reasons why they could enhance the positive effects of the SDOH in your area.
G. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
H. Demonstrate professional communication in the content and presentation of your submission.
HSC Orientation Manual
Name
Department, Institution Affiliation
Course Code; Course Name
Instructor's Name
Date
Table of Contents
1.0 Chapter 1: Medicaid/Medicare Reimbursement………………………………………………4
1.1. Medicaid Reimbursement Requirements ……………………………………………4
1.2. Methods to promote Medicaid Reimbursement Compliance………………………..4
1.3. Medicaid Reimbursement Regulations ……………………………………………...5
1.4. Medicaid Reimbursement Requirements…………………………………………….5
1.5. Methods to promote Medicaid Reimbursement Compliance ……………………….6
1.6. Medicaid Reimbursement Regulations ……………………………………………..6
2.0: Chapter 2: HMO/PPO Plans………………………………………………………………...7
2.1. Standard Mechanism for an appeal of denial of coverage ………………………….7
2.2. Reimbursement Limitations ………………………………………………………...7
3.0: Role of the HSC……………………………………………………………………………..7
3.1. Job Tasks for the HSC …………………………………………………….…….…..7
3.2. Job tasks and SDOHs......................................................................................... …....8
3.3. Ethical Dilemmas of HSC role ………………………………………………………8
3.4. Justification of the Dilemmas …………………………………………………..……9
4.0: Community Resources and Programs………………………………………………..………9
4.1. Existing Community Resources ………………………………………….…………9
4.2. Needed Community Resources ……………………………………………………..9
4.3. Reason for the needed Community Resources……………………………….……..10
4.4. Reasons to enhance Positive effects………………………………………….……..10
1.0: Chapter 1: Medicare/Medicaid
1.1. Medicare Reimbursement Requirements
The first reimbursement requirement is that individuals of 65 years and above are the only ones eligible for reimbursement. The identified group must have paid Medicare taxes for at least one decade (CMS, 2022). Whenever an individual meets the identified requirement, they can receive Medicare.
The second requirement is a disability condition. A disabled individual under 65 years can still benefit from Medicare reimbursement, and they must show that they receive RRB disability benefits or SSD benefits for at least two years.
The last requirement is evidence of continuing dialysis for a kidney transplant or renal disease. An individual successfully benefits from Medicaid whenever they show the identified condition of renal complexity.
1.2. Methods to promote Medicare Reimbursement Compliance
The first method to ensure a facility complies with Medicare reimbursement is limiting kickbacks. It prevents the physician from engaging in personal gain through referrals, and an organization is prohibited from such activity.
The second method is regulation by the CMS. CMS is an organization that ensures all organizations comply with the reimbursement requirements (CMS, 2022). Firms that do not uphold the requirements face specific penalties such as license withdrawal.
The last method of ensuring compliance is using whistleblowers. The whistleblowers are used to report any false claims that different organizations practice. The whistleblowers are paid a specific amount of money once they report such claims. The method allows the firms to stick to regulatory measures.
1.3. Medicare Reimbursement Regulations
The Stark law is the first regulation that promotes smooth Medicaid reimbursement. It limits the physicians from referring the clients to health services paid through Medicare based on ethnic or financial relationship.
The first second is the anti-kickback statute. It limits the physician from engaging in any activity, such as referrals through financial payment (CMS, 2022). It also limits any possibility of taking advantage of the reimbursed Medicare resources.
The last Medicare regulation is the false claim act. The regulations prevent reimbursement of Medicare due to false statements or conduct. For instance, an individual providing false information to access the Medicare program.
1.4. Medicaid Reimbursement Requirements
The first reimbursement requirement is low income. Despite the different requirements depending on the state, Medicaid reimbursement is specifically meant for low-income families (Alley et al., 2016). It does not depend on age.
The second reimbursement requirement is based on pregnant women. Most American states consider pregnant women in Medicaid reimbursement regardless of the other socio-economic factors (Britton, 2015). Therefore, it caters for the financially unstable.
The last requirement is PPACA. It is the determination of Medicaid eligibility by conducting a modified gross income test to ensure an indiv...