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Running head: THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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Third-Party Payment Systems and Planning in Healthcare
Name
Institutional Affiliation
THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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Third-Party Payment Systems and Planning in Healthcare
Third party payer system consists of the private organizations and the government who
take the role of paying for the medical bills of the patient who are not able to afford the hospital
charges or health insurance. The policy has contributed to several problems in the reimbursement
of physicians who take part in the provision of treatment with the hopes that they will get paid.
One of the significant impacts in the physician reimbursement due to the third party payment
system is the delayed payment due to the complicated procedure and guideline to be followed
before the bills for health service are provided (Clemens & Gottlieb, 2017). Moreover, failure to
provide full information on the medication may result in underpayment of the medics hence
lowering their income. The development of proper third-party payment systems promotes
efficiency, transparency, and accountability of an organization.
Reporting Requirements
The reporting guideline for the third party payer system requires that the bill should be
paid within the thirty days of the reception and acceptance of the medical material. There is a
need for the claim form that indicates the information required for the reimbursement process
and the making of the payment. The claim form should contain legible, accurate, and complete
data and attachment of any other additional document relevant for the amount (Noland &
Mentch, 2014). The reporting requirements provide an opportunity for the health leaders to carter
for all related costs in the payment. However, it becomes time-consuming and challenging to
collect all the medication information for the amount. Hence, healthcare leaders spend most of
their time analyzing and managing relevant data on the patient to be provided to the third party
payer.
Compliance Standards and Financial Principles
THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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The healthcare uses financial management principles in planning and ensuring that the
third party meets the reimbursement requirements. Through the application of the rule of
accountability, health organizations are required to explain how they have used their resources
and the health outcome they have achieved. The principle of transparency requires the health
providers to be open about their work and provide every detail of their services to the third party
(Gitman, Juchau, & Flanagan, 2015). Consequently, the principle of integrity is used in health
planning to ensure that there is honesty between the health provider and the third party payer.
Reimbursement Methods
The Principle of consistency can be used by the health organization to ensure that the
health outcome remains consistent and that the data provided do not conflict with each other. The
claim provides specific guidelines to be followed to ensure full payment of bills. Therefore,
guaranteeing full refund requires following and keeping up to the requirements stated in the
guide. There should be a publication of the reimbursement guideline within the institution to
provide all the physicians are made aware of the rules (Sanders et al., 2016). Publication act as
means of advertisement which establishes the rules and regulation familiar to the health
providers. Inclusively, organizations should encourage a culture of transparency, accountability,
and integrity which is guided by provisions to ensure all the physicians keep up to the
requirements.
Operational and Strategic Planning
Operational strategies of improving performance measure include reliance and insisting
on the quality of care for patients. Kuhn and Lehn (2015) argue that the ability of the health
provider to achieve quality health outcome among its patients results in maximized
reimbursement. Also, the management of the human resource through the division of labor and
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THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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assignment of the task to specific individuals can improve health outcome thus resulting in
increased pay. From the benchmarking data, it is recommended to monitor performance
measures such as the quality of health service, the time taken for treatment and the cost involved
as means increasing the reimbursement of the organization (Anderson et al., 2014).
Teamwork and Strategic Planning
Through the principles of training and development, the health providers can gain more
knowledge and become skilled thus increasing the quality of care. The appropriate skill mix
within the organization leads to improved quality, utilization of time and low cost of healthcare
which is essential in increasing the reimbursement. Also, supportive team climates, respect for
each other, and understanding of roles increases the efficiency and speed of healthcare delivery
which positively affects the payment.
Communication and Strategic Planning Across Teams
According to Cassidy (2016), health organization can use communicate their strategic
information through keeping the message simple for easy understanding, inspiring the message,
educating it among those who do not understand then reinforcing it into the healthcare system.
The organization can also develop a communication relationship model (CRM) to promote
communication among the management, personnel, and consumers. The process prevents
misinterpretation of information while promoting real-time interaction among stakeholders.
Financial Reimbursement
In a high performing health care system, the organization should adopt the cost
reimbursement system of payment. In this kind of payment, the health provider is paid for all the
allowed expenses and an additional fee for profits to given limits (Centers for Medicare &
Medicaid Services, 2016). The method provides for the health provider to be paid a fixed amount
THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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regardless of the expenses incurred; hence the process considers the quality of health in its
payment. On the other hand, low performing healthcare should adopt the prospective payment
system. The strategy involves a predetermined pay irrespective of the quality, cost, time spent in
servicing patient thus allowing for normal cash flow without any deduction.
THIRD-PARTY PAYMENT SYSTEMS AND PLANNING IN HEALTHCARE
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References
Anderson, J. L., Heidenreich, P. A., Barnett, P. G., Creager, M. A., Fonarow, G. C., Gibbons, R.
J., & Masoudi, F. A. (2014). ACC/AHA statement on cost/value methodology in
clinical
practice guidelines and performance measures: a report of the American College
of
Cardiology/American Heart Association Task Force on Performance Measures and
Task
Force on Practice Guidelines.
Journal of the American College of
Cardiology
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63
(21), 2304-
2322.
Cassidy, A. (2016).
A practical guide to information systems strategic planning
. Auerbach
Publications.
Centers for Medicare & Medicaid Services (CMS), HHS. (2016). Medicare Program; Merit-
Based Incentive Payment System (MIPS) and Alternative Payment Model (APM)
incentive under the physician fee schedule, and criteria for physician-focused payment
models. Final rule with comment period.
Federal register
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(214), 77008.
Clemens, J., & Gottlieb, J. D. (2017). In the shadow of a giant: Medicare’s influence on private
physician payments.
Journal of Political Economy
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125
(1), 1-39.
Gitman, L. J., Juchau, R., & Flanagan, J. (2015).
Principles of managerial finance
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Higher Education AU.
Kuhn, B., & Lehn, C. (2015). Value-based reimbursement: the banner health network
experience.
Frontiers of health services management
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Noland, J., & Mentch, C. (2014).
U.S. Patent No. 8,712,800
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Sanders, G. D., Neumann, P. J., Basu, A., Brock, D. W., Feeny, D., Krahn, M., ... & Salomon, J.
A. (2016). Recommendations for conduct, methodological practices, and reporting of
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cost-effectiveness analyses: second panel on cost-effectiveness in health and
medicine.
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