Fee For Service Utilization And Reimbursement

Moreover, we see that some providers are focusing on what providers do and how they get reimbursed rather than what the patient needs, which is a focus that does not prioritize quality of care and therefore does not align with the Triple Aim framework. The problem presented regarding this matter is that the health care system lacks a patient-focused care of medical conditions that puts patients and their health needs first. For example, when we think of provider reimbursement, it is not in the patient’s best interest for the system to only have a simple fee-for-service structure. A structure like this one will only lead to an increase of health care expenses. Also, it fails to incentivize high-value service, which also does not align with the Triple Aim framework health care providers should go by. It is very crucial for the health care system in the United Stated to find a better balance between medical groups reimbursement and patients needs in order to reduce the risk of overutilization.

However, when Private insurance companies soon joined the fray thereby creating stiff competition, costs were determined by a number of factors among them was the exclusion of the sick and the selective process of insuring only the healthy which meant more profit for the company because Blue Cross only provided coverage for hospital services. The Blue Shield plans were created in 1939 by employers in lumber and mining. This was done to ease the healthcare burden and bring satisfaction to both the physician and the patient. In 1982, The Blue Shield plan merged with The Blue Cross to form The Blue Cross and Blue Shield Association(4).

Obtaining reimbursement for services provided is a necessity for the survival of many health care organizations. This paper will explain, in my opinion, why the Centers for Medicare and Medicaid Services (CMS) are involved in this development and how it affects the American public. I will offer a suggestion to ensure meeting policy and procedure. I will finish by discussing three ideas listed on the CMS website.

Through the history of health care, the standard of care changed from protecting our patient from injury and illness to a systemic entity to make money for insurance companies. Access to services and clinical outcomes are dependent on what health insurance providers will “pay” for in a clinical or community setting; as a result, patient safety, care and satisfaction has been negatively impacted.

Based on the political and economic environments of states and the federal government the methods of health care reimbursement have been required to evolve. With the introduction of the Patient Protection and Affordable Care Act (PPACA) new laws have been set into place that has caused a stringent review of spending on health care. All care provided is being examined for effectiveness, quality, and the actual need of the service. Unnecessary health care functions are being screened and eliminated. The government and other insurance providers have begun to place cost containment measures in place only paying for those procedures that are deemed medically necessary for the illness that the patient is currently afflicted with. This has a direct impact on the monies that the government and insurance providers will reimburse for services. The following paper will look at the major types of reimbursement activates currently in place. The writer of this paper will also speculate on the future of health care reimbursement and how it will affect his current organization.

Any proposed policy to improve healthcare must address the current payment method, and the rising cost of healthcare. The common reimbursement method for healthcare services is the fee-for-service payment model. It requires providers to figure-out all incurred costs to render services for patients. Additionally, providers need to determine what is the insurer proposing to pay, which thought to reward quantity over quality. An alternative to this model is using a bundle

The real problem as pertains to the reimbursement of managed care organizations is that these managed care has had an effect on slowing the rates of growth concerning the costs of hospitals and specialist physicians. For both the hospitals and practitioners, the sources of revenue have been shifted with over 20 percent of the charges being paid from the pocket, others coming from third parties who demand for complex accounting of the charges, lack a pre-authorization process and they can review in a retrospective manner and deny the reimbursement (Furrow et al., 2013). The

The managed health care system is a complex process that must align financial incentives and goals. Therefore, managed care is thought of as a complex puzzle that once one piece is moved it will affect the outcomes of the rest of the system (Boyd & Finamn, 2010). As a result, it is essential that the managed care organization have the ability to align its financial incentives with the goals of all parties involved, such as the providers who deliver healthcare services and the health insurance plan with its benefits. The purpose of this paper is to assess the history of managed care.

Healthcare in itself in the United States is a budding concept. The first ever insurance plans would pop up during the Civil War from 1861 to 1865. In 1929, there would be a formation of the first health plan for a group of people. This would take place by a group of teachers in Dallas, Texas, they would be contracted with Baylor Hospital to provide rooms, board, and medical services this would be in exchange for a monthly fee that would be charged by the hospital. There would be several large life insurance companies that would decide to enter the field of healthcare starting from the 1930 's to 1940 's as health insurance would grow in its popularity ("The History of Health Insurance," 2007).

The Centers for Medicare or Medicaid services enforces utilization management to make sure the services being provided are relevant or necessary (Gartee, 2011). Also, a reimbursement rate for services were set forth to make sure the the health care organization did not charge the patient more than the approved amount.

managed care grew more in the last years, bringing about new types of managed care plans through competing MCOs. To make their plans more attractive, organizations used payment variations. For instance, instead of capitation, PPOs used discounted fees payment. There were ones that offered enrollees choices between affiliated providers and non-affiliated providers. MCOs also adopted various methods to control health care costs by actively monitoring utilization (Shi, Singh, 2017). Additionally, private health insurance, as well as high deductible health plans, can be offered as managed care plans nowadays. Also, available to Medicare and Medicaid recipients is the option to enroll in a managed care plan or continuing to stay with the traditional fee-for service program. Now for specific services HMOs incorporates capitation and fee-for-service reimbursement, in their payment schemes.

3. Evidences say that physicians who are paid under FFS happen to treat patients with excess services and procedures than those who who are paid by other methods like capitation (Gosden, Forland, Kristiansen, et al., 2000). (Gosden T, Forland F, Kristiansen IS, et al. (2000). "Capitation, salary, fee-for-service and mixed

First, we must examine how we got to our current situation today here in the United States. The U.S. Healthcare system comprises a convoluted patchwork of public and private programs that have functioned at variable degrees of success over the years. Coverage in the U.S. has traditionally been offered through one’s employment, although employment alone does not guarantee that an employer will offer insurance. Although a plan for a national health insurance scheme had been in the works under Nixon, any hopes of witnessing its implementation died with his resignation (Toland).

Many have felt that the intentions of this new enactment were to prevent Americans from receiving the proper care that is needed. However, within managed care organizations is the ability to provide all those Americans with better and more affordable care. The formation of managed care organizations grew rapidly during the Great Depression, “not because consumers were demanding insurance against the risk of medical expenses or because nonphysician entrepreneurs were seeking to establish a business, but rather because providers wanted to maintain and enhance patient revenues” (Kongstvedt, 2). There was a major increase to company wide health care organizations when the government decided to enact the federal Health Maintenance Organization Act. This act “authorized start-up funding and ensured access to the employer based health insurance market” (Kongstvedt, 4). Many advocates of managed care organizations like to point out that, “managed care is unique in that it did not arise out of a specific legislative initiative but instead represents a market response” (Health Care Manager, 54). From this we are better able to understand that the wishes of consumers of traditional health care programs felt that something needed to be improved for success. Now that we know where managed care started, we can venture in to how it has evolved throughout the

The system adopted the official name of Blue Cross in 1939 and similarly physician groups developed Blue Shield plans. Commercial health insurers made their presence known in the U.S. market post–World War II when workers started demanding health insurance as a fringe benefit from employers. Medicare, a government insurance program mainly for people above the age of 65 was introduced in 1965 and in the same year, Medicaid was created as a social program providing insurance to low- income citizens. The 1980’s witnessed growth of managed care plans as a means of controlling healthcare costs and in the 1990’s there were several mergers and acquisitions and the restructuring of the Blue Cross and Blue Shield as well as commercial insurers. These mergers and acquisitions have consolidated the health insurance market, which is now dominated by a few players.