Cost Based Reimbursement Essay

Third party – Reimbursement payments made by an insurance company that provides benefits for the

It is essential for an administrator to understand how private and government payers impact actual reimbursement. Government payers have a standardized benefit structure. The one benefit is that registration staff have an easier time calculating payment due (copayments) for service and can set up payment arrangements. Since the most significant proportion of funds coming into a healthcare organization is usually payments from third-party payers, therefore, it is critical to know how each reimbursement affect the others that come in. Healthcare organization may have hundreds of different payer’s relationships in the form of different contracts that have their own rates of payment that are usually different from other payers for an identical

Unit 2 AssignmentKelley WhitcombKaplan UniversityHI215-01: Reimbursement MethodologiesProfessor Kathleen SobelJuly 20, 2015Medicaid is one of the biggest insurance plans you can get in any state. In the state of Indiana, it is based off of your income. There is a certain amount (income) you have to make to determine if you will receive Medicaid or Healthy Indiana Plan (HIP). HIP is still a form of Medicaid, but you would have to pay monthly cost for it and have certain set of co-pays for certain services that is needed. HIP Plus is the recommended plan for members as it provides health coverage for a low, predictable monthly cost. HIP Plus also covers dental and vision services. If you do not pay your monthly payment you can be removed from

Since 1984, Medicare patients have been serviced under the prospective payment system of the Medicare program. Under this system, primary care providers are reimbursed for their services using a fixed payment for each patient that is determined by the patient’s diagnosis-related group at the time of the admission. Therefore, under the prospective payment system a hospital’s reimbursement is unaffected by the actual expenditures that are required to care for a patient.

Discuss the general differences between facility and non-facility rates. Discuss the MS-DRG system for hospital inpatient services. Include in your discussion the history of the MS-DRG system and the need for the updated system. There are two types of bills used in healthcare. Which type of bill is used for physician services? Which type of bill is used for hospital services? (Hint: your book is incorrect.)

directly by the patient’s health insurance provider which are termed the payer. 68% of the United States

One major trend in the healthcare environment is the shift from volume based reimbursement towards value based reimbursement. Many provider practices remain on a volume based or fee for service reimbursement plan. This system tends to reward high quantity of services with less regard for the quality or performance of the service. However, with a renewed focus on value, reimbursement plans

Revenue determination is an important tool for health care organizations because it allows for efficient management of payment systems. This paper will look at the different components that form the payment-determination bases of revenue determination. Moreover, the difference between specific and bundled service payments will be discussed. Lastly, the three ways health care providers control their revenue function will be highlighted.

In healthcare systems there are third party payers. A third party payer is an insurance coverage that pays the healthcare provider for service

Fee for service, as the name suggest is a method in which the healthcare provider is paid individually for each and every service provided. In this method the numbers of services determine the amount of reimbursement. This is where the healthcare providers misuse their authority and either provides more services than what is needed or just manipulate the number of services provided. There are specific

The United States currently employs a multipayer system. The payers in this system include the government and private insurance companies., thus the collection of money for health care is a joint responsibility of both parties. Private insurance companies collect premiums and other payments from enrolled individuals and businesses. The government collects taxes from individuals and businesses. Regarding reimbursement, the private insurance industry reimburses providers for health care services delivered to privately insured individuals, while the government reimburses providers for health care services delivered to publicly insured individuals (e.g. people enrolled in Medicare, Medicaid, S-CHIP, or the VA).

Depending on the insurer and the type of service provided, third-party payers pay providers by different means

To review all the different ways healthcare services are paid will take alot more then a few paragraphs. Private payors have contracts with employers and with providers. Each plan can be different in the payment of services. In my personel experience, contract especially at truma hospitals are typically based on % of charges.

Bundled Pricing: As quoted by Zezza, Guterman and Smith in 2012, “In this type of payment system, a single payment is made for an episode of care—a defined set of services delivered by designated providers in specified health care settings, usually delivered within a certain period of time, related to treating a patient’s medical condition or performing a major surgical procedure.” Encouraging the physicians, hospitals to work together and coordinate the care of patients, to decrease re-hospitalizations, to improve the transition of care and to ensure proper care delivery after discharge is the ultimate goal of this payment plan (Zezza et. al., 2012).

A third party payer is an organization(s) that reimburses money to physician according to the level of care and treatment that was rendered to the insured member. This payment system represent cost sharing they individuals, about 84.6% of Americans, who elected to pay a set rate in exchange for the access to medical care and service (Buchbinder & Shanks, 2012). Well, the healthcare (HA) system is not longer that simple. The HC system is mandate that legislative and mandates t and most will agree there are that I have HC