Reimbursement Definition

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

The American human services framework is experiencing a rapid shift that incorporated a movement from fee-for-service payment into value-based payment that rely profoundly upon the provider integration plus care coordination (Santo, 2014). Value- based installment attempt to realign the economic incentive regarding care delivery by integrating doctors pay to value and quality. The FCA and AKS, are regulatory structures that were basically created to handle fraud and abuse claims emerging from the fee- for-service reimbursement framework.

The key elements to a healthy and successful medical practice are a reliable and properly trained staff and a sound revenue cycle that produces satisfactory reimbursement. Revenue cycle management starts at the front-end with pre-registration of the patient. Complete and accurate recording of patient insurance and billing information is imperative. Insurance verification plays a major role in the assurance of reimbursement. The front desk should counsel and confirm financial responsibility with the patient during the registration process. Patient encounter is equally as important. Correct coding of patient diagnosis and procedures minimizes the likelihood of claim rejection. The next step in the revenue cycle is claim submission. The claims process begins with the provider treating the patient then sending a bill to the designated payer. Before the bill is sent, a certified coding specialist or medical billing specialist prepares and reviews the claim for any inaccuracies. There are a few ways the claim is submitted, either manually or electronically. Once the claim is submitted, follow-up with third party payers is a necessary step in the

There is a growing trend in the United States called pay-for-performance. Pay-for-performance is a system that is used where providers are compensated by payers for meeting certain pre-established measures for quality and efficiency (What is Pay-for-Performance, n.a.). We are going to be discussing what pay-for-performance is. There are different aspects of pay-for-performance which include; the effects of reimbursement by this approach, the impact cost reductions has on quality and efficiency of health care, the affects to the providers and patients, and the effects on the future of health care.

It is important to follow payer guidelines when completing a claim form; otherwise, reimbursement will be delayed until the form is corrected.

The policy issue that I have selected to discuss herein is the pay-for-performance payment model. I feel that this impacts a large number of our population and changes in this regard should be made. This type of payment model aims to use reimbursement to incentivize providers to deliver high quality services. Pay-for-performance model steps away from the traditional manner of reimbursement of fee-for-service, in which providers receive payment on the basis of frequency or volume of the services they provide regardless of outcomes. In contrast,

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

In the past several years, there have been several changes in economic policy at federal and state levels. The two economic policies that present to be the most precedent for healthcare leaders with concern to facility reimbursement are the Affordable Care Act (ACA) and the switch from volume to value reimbursement. First, there is the ACA policy, which have affected healthcare facilities and their reimbursement methods. In fact, ever since this policy was implemented, provider reimbursement has started to decrease in terms of fee-for-service payments (The Common-Wealth Fund, 2015). In other words, the intention of this policy was to provide budget relief to the government payers as well as giving providers an incentive to provider patients with great quality of care.

In the United States, health care has become a huge expense and has threatened the economy; additional measures need to be taken to address the rising cost of care. An individual spends an estimated eight thousand dollars a year in health care expenditures. Therefore, we need to recognize that how a physician reimbursement for payment has a vast impact on the economy and the rising cost of health care.

This exercise point out some very important factors with regard to health care cost.  nursing homes and other health care delivery systems are faced with significant shortfalls in reimbursement for various reasons.  Medicare reimbursement often does not cover the full extent of treatment of individuals.  McPike (2008) notes that, “The insurance and hospital industries released a study today showing that underpayment by Medicare and Medicaid costs consumers and employers $88 billion more a year for health care as providers attempt to make up the difference.” Today with continue cutbacks in medicare reimbursement this number is significantly higher.  In an attempt to reclaim these losses, both self pay and privately insured patients are charge

The service-based pay structure provides significant motivation for healthcare providers to deliver as many services as possible, with little to no consideration of patient outcomes. Furthermore, this structure provides no incentive for certain key elements of healthcare such as patient education and care coordination, both of which have led to diminished costs and better outcomes for patients. I am of the opinion that very little quality improvement will take place if this pay-for-service model persists. The current transition from service-based pay to quality-based pay is definitely a move in the right

Another issue for fee-for-service system is that the providers set the prices for services. Patients were free to seek any type of healthcare services that they thought they required, while providers set the costs for each service that was billed to indemnity insurance companies (Shi & Singh, 2015). Insurance companies had little control on the types of services that the patient received and prices billed for each service. The fee-for-service model encourages excessive and unwarranted procedures and offers no incentives to utilize economical services (Smith, 2010). While the patients enjoy the freedom of being able to seek out their own services, over-utilization of expensive services on unnecessary and highly technical services increased healthcare costs.

Another factor that has contributed to the over-utilization and increased treatment charges is the fact that providers set the prices for services. Patients were free to seek any type of healthcare services that they thought they required for their well-being, while providers set the costs for each service that was billed to indemnity insurance companies (Shi & Singh, 2015). Insurance companies had little control on the types of services that the patient received and prices billed for each service. The fee-for-service model encourages excessive and unwarranted procedures and offers no incentives to utilize economical services

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.

Under payment, an ideal healthcare system will have the challenge of delivering higher quality for lower costs. The system’s payment reform will involve a transition from fee-for-service to global from systems that are value-based important for the achievement of the overall healthcare goals. An ideal healthcare payment system will give a great deal of support to value-driven system of healthcare delivery (Kent, 2013). The fee-for-service payment system will be of great importance to the healthcare system as it will help control the costs of health care.