Reasons For Working And Meeting Expectations Of The Not For Profit

Healthcare is often driven by consumers and insurance companies; there is strong pushes for insurance companies to start paying better through Patient Care Medical Homes (PCMH) or Accountable Care Organizations (ACO) rather than paying at a per-visit basis (Hamlin, 2015). With PCMH or ACOs payment is made on a continuum of care, encouraging the provider to be involved in all aspects affecting health of the patient (Derksen, & Whelan,

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.

The role of finance in Health Care Systems, Inc. as a regional not-for-profit hospital relates to both the accounting and financial management aspects of the business. Facets of both accounting and financial management are intertwined with maximizing productivity by way of managing and analyzing financial operations to ensure resources are being utilized properly (Gapensiki, 2013). The divulgence of financial reports to managers and investors will aid in the development of plans and budgets for future growth, assess acceptable levels of financial risk, manage contracts appropriately and make decisions related to capital investments allowing the organization to expand service offerings thereby demonstrating greater value in the community. Operating as a not-for-profit entity requires that the hospital operate exclusively in the interest of the public for a charitable purpose. Through understanding who the primary third party payers

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

The debate over non-profit versus for-profit healthcare organization has been ongoing, does one provide better care than the other? Do the operations of for profit perform better than the non-profit organizations? Are the criticisms about for-profit organization validated and is there proof? The goal is to examine those questions as well as offer options to improve the financial and operational performance of non-profit and for-profit organizations criticisms.

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.

First of all let us understand the concept of third party payer. Third-party payers are the insurers that reimburse health services organizations and hence are the major source of revenues for most providers. large proportion of provider revenues does not come directly from patients (the users of healthcare services) but from insurers, known collectively as third-party payers. It include private insurers, such as Blue Cross and Blue Shield, and public (government) insurers, such as Medicare and Medicaid. Third-party payers use several reimbursement methods to pay providers, depending on the specific payer (e.g., the Blues versus Medicare) and the type of service rendered (e.g., inpatient versus outpatient).

The White Paper released by the Camden Group and presented for review by the contributing authors (Rebecca Bales, Kelly Tiberio, and Tara Tesch) offers a perspective from one of the nation’s leading Health Care advisory firms. The paper brings to the forefront the characteristics of Non-Profit and for-profit hospitals, and the outlook for conversion from one industry classification (Non-Profit into a For-profit) business entity. Contained within the paper are a wide-range of topics with regards to the similarities between the two health care models, laws and regulations from both the State & Federal levels that guide their respective classification, market outlook for the health care industry and case studies that highlight the impact of actual conversion from Non-profit to For-profit hospitals from an industry standpoint. The health care is a challenging and competitive environment, therefore the paper focuses on providing insight on a strategy based on adapting from one business model into another in order to remain competitive.

With these types of organizations they have different methods of payments and reimbursements. They have guidelines through the government that they will have to abide by. The government sponsored payers are Medicaid and Medicare. The majority of patients that are treated are on Medicare or Medicaid. With patients not insured each type of organization handles reimbursement differently. For- Profit hospitals it is bad debt, which is when charges of patient are written off. With not –for –profit organizations it is considered charity care. This type of care has to be documented and reported on tax status.

Private insurance companies negotiate prices with hospitals and health care providers to confirm what will be paid by the insurer. These negotiations can be taxing as both entities fight for what is most profitable for them. The providers involved with the negotiations are “in network providers” and all others fall into the out of network realm and run the risk of not being reimbursed or being paid a certain amount leaving it up to the consumer to pick up the remaining balance. Managed care provides a system by which the priority of health care is to reduce costs while ensuring that the delivery of quality health care is provided to consumers. The different types of managed care organizations include Health Maintenance Organization (HMO) and Preferred Provider Organization (PPO) and both systems follow different payment methods. HMO’s use capitation or fixed annual payments for each person its exclusive list of providers sees no matter what type of care or how much care is provided and PPO’s, like traditional insurance companies, negotiate rates of payment with providers and members enjoy lower out of pocket costs such as deductibles and copays. With PPO’s, members could choose out of network providers and would pay the difference between the reimbursement rate of the plan and the changes of the

In my area and throughout the city of Los Angles, the not-for-profit organization, Coalition to Abolish Slavery & Trafficking (CAST) has plenty of resources for survivors of sex trafficking and exploration. CAST is a multi-ethnic, “multi-lingual human rights organization that has been nationally and internationally recognized for its dedication to the identification of trafficking survivors.” (CAST, About Us, n.d.) CAST was the “first organization in the country dedicated exclusively to serving survivors of human trafficking and modern-day slavery.” CAST is the only “organization in the country that offers all three branches of services in-house (social services, shelter, and legal services), without all three, the victims could not become survivors” (CAST, Client Services Program, n.d.). Branch 1 CAST social services help clients to recover from years of abuse and trauma so they can become self-sufficient and thriving members of our community (CAST, Social Services, n.d.). Services include access

The first Party paying is the Patient (or Parent if a minor involve), second party is the Providers and the third party is the insurance company/health agency.

Managed care and integrated systems provided a review of the history of the reimbursement within healthcare and then the current options for reimbursement in healthcare. Other topics include different insurance companies and the government’s role in the healthcare today.

Several studies in the NFP and for-profit sector were used to form Surysekar, et. al’s hypothesis. The previous studies found the following: 1) the link between NFP performance and financial