HITT217 Health Insurance And Reimbursement

Question Prompt: Write a draft of the Third-Party Payment Systems and the Operational and Strategic Planning in Healthcare portions of your research and analysis. Specifically, the following critical elements must be addressed: Third-Party Payment Systems: a) Healthcare System Reimbursement:Evaluate third-party payer models for the impacts they present on healthcare system reimbursement. b) Reporting Requirements: Analyze the reporting guidelines of third-party payer payment systems. What opportunities and challenges do they present for healthcare leaders in meeting reporting requirements? c) Compliance Standardsand Financial Principles: Analyze how healthcare organizations in general utilize financial principles to guide strategic planning to ensure the meeting of third-party submission requirements. d) Reimbursement Methods: Considering third-party payer systems, what strategies would you recommend organizations implement in order to receive full reimbursement on claims as well as to improve timeliness of this reimbursement? Be sure to justify your recommendations. Operational And Strategic Planning In Healthcare: a) Pay-For-Performance Incentives: Based on your prior analysis of the impact of case rates and management utilization data on pay-for performance incentives, recommend appropriate operational strategies to improve performance measures that will maximize reimbursement. Be sure to provide support for your recommendations. b) Operational Performance Measures: Considering benchmarking data, recommend performance measures that should be monitored for the purpose of maximizing reimbursement. c) Teamwork and Strategic Planning: Recommend collaborative teamwork principles that would be beneficial for healthcare strategic planning in terms of reimbursement. Be sure to provide support for your recommendations. d) Communicating Strategic PlanningAcross Teams: What types of tools or strategies would you recommend for communicating strategic planning conclusions to key stakeholders, members of cross-disciplinary teams, and the rest of the organization? In other words, how would you communicate strategic planning information to clinical vs. non-clinical staff? To administrative staff? Be sure to provide support for your recommendations. e) Financial and Reimbursement Strategies: Considering cash flow and days in accounts receivable for hospital and health systems, recommend reimbursement strategies that would be appropriate for low- and high-performing health systems. Provide evidence to support your conclusion. Answer Third Party Payment System A. Healthcare System Reimbursement Third party models for the impact they pay includes fess for service, health maintenance organization, Independent practice association, managed care, Point of service, preferred provider organisation. These models cater to authorize the reimbursement policies through a significant plan that helps to impose on understanding the impact on healthcare system reimbursement. The fee for service payment system also caters to reflect a positive analysis for the patient during the service. The models stated above have their individual plans to guide patients while paying the health sector bills. The managed care model sets an agenda to the reimbursement policies that can be established within a definite patient service. The respective understanding of point of service and preferred provider in healthcare reimbursement resolves the idea of repayment assistance with a lesser issues within the healthcare setup. The models also reflect in creating an impact on the medical policies. In fact, the reimbursement is directly related to grow with a constant understanding of establishing the categorical replacement of the total amount paid by the service user. Healthcare system reimbursement indicates the repayment system incurred within a healthcare organization during or after a treatment procedure is conducted. As per Diaby & Goeree (2014), insurance providers or government payers are entitled to pay treatment amounts. However, this also depends on the policy taken up by the respective service user. On such scenarios of entitlement, the financial institutions need the entire documentation of on spot payment to reimburse respective service user. Third party payer model includes insurance companies, employers, government agencies and others that includes in the list of reimburse panels. B. Reporting Requirements Third party payer payment system should report in chronological order as it includes third party payers such as insurance companies, government agencies, employers and others. According to Dombret et al. (2016), opportunities can identify by their system of payment and they can develop by considering different payment options. In case of reimbursement, the primary requirements include documented papers reflecting the payment made by the service users. In fact, the insurance policy also needs a through revision whether the amount paid will be provided by the service provided. On noticing the policy terms and condition, the hospital authority might help in contacting the policy makers and transmit the details to the policy holders. Apart from this, the receipt or any softcopy documentation is mandatory to reflect the spot payment. C. Compliance Standards And Financial Principles Healthcare organizations generally follow financial principles along with compliance standards for meeting the requirement of third party reimbursement submission. In the viewpoint of Garrison & Towse (2017), they also follow some accounting standards that provide them better financial stability in their whole process of reimbursement. Regulatory compliance mainly identifies goals and objectives of a healthcare organization and also follows some steps that are totally relevant to laws, regulations and policies of an organization. D. Reimbursement Methods Reimbursement policies are primarily chosen by the healthcare organization. In reflection to understand the type of reimbursement methods, the authority and policy makers can guide through. Discount from billed charges is one method that generally considers the bill that is drawn against the amount of money that is incurred as medical expenses. Godefrooij et al. (2017) stated that discount is applied on those bills and healthcare providers reimburse a certain amount. Fee for service is another method in which a certain amount of money is charged as fees for providing medical services. Bundled payments are considered in large healthcare providers where huge amount of bills are reimbursed for a certain period and then it is reimbursed at a certain time. Therefore, bundled payment and discount from billed charges might recommend as they are considered in large sectors where huge amount of money are reimbursed. Operational And Strategic Planning In Healthcare A. Pay For Performance Incentives Pay for performance incentives is an operational as well as strategic planning where an employee gets a certain amount of incentives according to their performance. Better performance receives better amount of incentives and it helps an organization to achieve their targeted goals and objectives. Mossialos et al. (2015) mentioned that it also helps an organization to improve in their overall performance that ultimately maximizes their reimbursement. It mainly motivates other employees to work more in a better way as they would get more incentives for their allocated task. B. Operational Performance Measures The management team should measure operational performance as it should be monitored for maximizing the purpose of reimbursement. Squires et al. (2015) opined that each operation should be properly monitored as it identifies performances of each task that are performed in normal course of business. C. Teamwork And Strategic Planning Teamwork and strategic planning should be properly maintained as it helps in overall performance of a healthcare provider. In the viewpoint of Diaby & Goeree (2014), teamwork helps in achieving the targeted goals and objectives in an effective and efficient way. Moreover, strategic planning can help in improvement of reimbursement policies catering to reflect a necessary teamwork and assistance to policy makers. D. Communicating Strategic Planning Communication among members and stakeholders should be maintained as it ensures proper strategic planning within a healthcare organization. Inspired from Garrison & Towse (2017), regular meeting should implement among stakeholders as it enhances the ideas that might help in developing overall services of healthcare providers. E. Financial And Reimbursement Strategies Financial strategies followed in healthcare system along with other accounts receivable that should consider for better financial management. Cash flow system must be prepared along with accounts receivables as it points out day-to-day transactions that take place in a normal course of business. Mossialos et al. (2015) stated that this financial statement shows the inflow and outflow of cash that takes place in healthcare providing services. It would increase overall performance of an organization that provides better financial support in their system of management. Reference List Diaby, V., & Goeree, R. (2014). How to use multi-criteria decision analysis methods for reimbursement decision-making in healthcare: a step-by-step guide. Expert review of pharmacoeconomics & outcomes research, 14(1), 81-99. Retrieved on 14 November 2018 retrieved from https://www.researchgate.net/profile/Vakaramoko_Diaby2/publication/259314450_How_to_use_multi-criteria_decision_analysis_methods_for_reimbursement_decision-making_in_healthcare_A_step-by-step_guide/links/5578fcb108aeb6d8c01f1cff.pdf Dombret, H., Thomas, X., Chevallier, P., Nivot, E., Reitan, J., Barber, B., … & Mohty, M. (2016). Healthcare burden and reimbursement of hospitalization during chemotherapy for adults with Ph-negative relapsed or refractory B-cell precursor acute lymphoblastic leukemia in France: a retrospective chart review. Journal of medical economics, 19(11), 1034-1039. Retrieved on 13 November 2018 retrieved from https://rjmgroupllc.com/wp-conten/tuploads/2011/04/Dombret_JME2016_FrenchALLchartreview.pdf Garrison, L., & Towse, A. (2017). Value-Based Pricing and Reimbursement in Personalised Healthcare: Introduction to the Basic Health Economics. Journal of personalized medicine, 7(3), 10-15. Retrieved on 12 November 2018 retrieved from https://www.mdpi.com/2075-4426/7/3/10/pdf Godefrooij, D. A., De Wit, G. A., Uiterwaal, C. S., Imhof, S. M., & Wisse, R. P. (2017). Age-specific incidence and prevalence of keratoconus: a nationwide registration study. American journal of ophthalmology, 175(2), 169-172. Retrieved on 11 November 2018 retrieved from https://dspace.library.uu.nl/bitstream/handle/1874/344385/Godefrooij.pdf?sequence=1#page=19 Mossialos, E., Courtin, E., Naci, H., Benrimoj, S., Bouvy, M., Farris, K., … & Sketris, I. (2015). From “retailers” to health care providers: transforming the role of community pharmacists in chronic disease management. Health Policy, 119(5), 628-639. Retrieved on 10 November 2018 retrieved from https://opus.lib.uts.edu.au/bitstream/10453/36006/1/Mossialos%20E%20et%20al_From%20retailers%20to%20health%20care%20providers.pdf Squires, M. H., Staley, C. A., Knechtle, W., Winer, J. H., Russell, M. C., Perez, S., … & Staley, C. A. (2015). Association between hospital finances, payer mix, and complications after hyperthermic intraperitoneal chemotherapy: deficiencies in the current healthcare reimbursement system and future implications. Annals of surgical oncology, 22(5), 1739-1745. Retrieved on 14 November 2018 retrieved from https://s3.amazonaws.com/academia.edu.documents/44509052/Squires_association_btwn_hospital_finances_payer_mix_complications_HIPEC.pdf?AWSAccessKeyId=AKIAIWOWYYGZ2Y53UL3A&Expires=1542262048&Signature=zFePFreVSq%2BNPTH0fptTOzvZkxA%3D&response-content-disposition=inline%3B%20filename%3DAssociation_Between_Hospital_Finances_Pa.pdf

HITT217 Health Insurance And Reimbursement

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