Healthcare Management Capstone- Individual Project 2
docx
keyboard_arrow_up
School
Colorado Technical University *
*We aren’t endorsed by this school
Course
HCM612-160
Subject
History
Date
Feb 20, 2024
Type
docx
Pages
6
Uploaded by CaptainCrownHorse33
1
Reimbursement Methodologies
Khadijah C. Rojas
Colorado Technical University
HSS491 Healthcare Management Capstone
Prof. Teresa Thomas
Date: 11/6/2022
HSS491 061222/ttb
2
Reimbursement Methodologies
Medical expense reimbursement has been paid for using a variety of payment mechanisms, each with varying levels of effectiveness. It is crucial that the systems that are developed employing each of these mechanisms, separately or in combination, provide accommodations that are appropriate for the amount, complexity, and caliber of care provided. Utilizing patient data to track doctor conduct, patient reaction, and healthcare organization operations can assist enhance the standard of medical care while also improving the accuracy and
effectiveness of payment procedures. The capitation technique, fee-for-service method, and bundled payment method are three popular reimbursement strategies used by healthcare organizations and providers.
Reimbursement Methods
Under the Capitation reimbursement method, healthcare professionals are paid a set amount per patient (Nelson, 2021)
. The providers that are compensated using the capitation mechanism receive regular monthly payments in addition to regular patient allocations. Whether or not the patient sessions are used is a factor in the payout. Because the suppliers know the monthly fee for each enrollee, they are unable to demand additional payments if the price rises over the payment. Due to the reimbursement system, doctors are more inclined to advise patients
to take preventative measures and pay close attention to reducing the number of trips they could require. Under the Fee-for service method, medical health care organizations, as well as providers, are compensated for each service and test they perform to a patient. This means that every test and every procedure is paid for by the healthcare organizations and providers. Contrary to medical professionals and organizations covered by capitation, under payment for service, there is no incentive to promote preventative measures or avoid expensive procedures HSS491 061222/ttb
3
and testing. Under the bundled payment, the healthcare providers are compensated for the specific health care episodes, such as inpatient hospital stays (LaPointe, 2016)
. This reimbursement approach encourages effectiveness and high standards of treatment and service. This is so that you can pay for the entire treatment episode with the predetermined amount of money. According to this method, the healthcare professionals are compensated for their care and attention of the patient's condition throughout the entire course of treatment. This covers the tools of support, the methods, the evaluations, the medications, and the equipment.
Method used for Facility
In a primary care facility, the best reimbursement method to use is the Fee-for service payment method. This method is known to be the most traditional method used throughout the healthcare system. Under this model, providers are reimbursed based on how many services and procedures provided to their patients. In primary care facilities, many services are provided. This
includes physicals, point of care testing, patient consultations, and any in clinic procedures provided. Pros and Cons
Before the value-based care movement, the most common type of health insurance was the fee-for-service plan (Rice, 2021). For those who can afford it, fee-for-service insurance, also referred to as indemnity plans, allows total independence and flexibility. With little interference from the insurance provider, patients are free to select the doctors and hospitals of their choice under fee-for-service plans.
Due to the possibility of customers being required to pay for their medical treatments up front and submit receipts for reimbursement, fee-for-service health plans typically involve out-of-pocket expenses. Patients receive excellent care, and the provider can make the right suggestions. Physicians can be flexible to provide their patients with accurate HSS491 061222/ttb
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help
4
support and can charge a fair price for a plan. Although fee-for services plans can be beneficial, there are also some downsides to it as well. Fee for service offers extremely little or no compensation for providing value-based, holistic care. Doctors who are paid on a fee-for-service basis are encouraged to practice "defensive medicine" and to order extraneous tests and treatments in order to increase their income. restricted to personal visits and acts as a barrier to the use of unorthodox treatments for illnesses. Due to the lack of financial accountability for patients and providers, fee for service causes an overall increase in healthcare expenses over time.
Impact of the Method
The fee-for-service approach has drawn a lot of criticism for overusing services and taxing third-party payers like government agencies or health insurance companies.
Even if lawmakers and government organizations support the switch from a fee-for-service to a value-
based care model, it is doubtful that providers would completely give up the fee-for-service model in the future. The Fee for Service concept has had a dilution of widespread adoption. Using the Fee for service model in a primary care facility, it will definitely increase profit for the
organization and providers as well. The fee for service model can benefit both the providers and patients because with providers being able to provide services to their patients in the clinic, they will obviously get paid for the services. As for the patients, being able to receive the necessary services through their primary care provider is very convenient because they won’t have to worry
about getting seen somewhere else for basic services and they won’t have to pay extra copayments.
Conclusion
The three reimbursement methods mentioned throughout this discussion, plays a huge HSS491 061222/ttb
5
part in the healthcare system. Depending on the type of facility, there may be one model that may work compared to the other models. I would say that providers need to be mindful of what choices they make when it comes to providing services to their patients because they can be costly and health insurances may cover a certain amount. This can leave patients with a bill they do not want, and this can look bad on the organization. HSS491 061222/ttb
6
References
LaPointe, J. (2016, July 14). Retrieved from Understanding the Basics of Bundled Payments in Healthcare: https://revcycleintelligence.com/news/understanding-the-basics-of-bundled-
payments-in-healthcare
Nelson, H. (2021, February 16). Retrieved from What are Capitation Reimbursement Models, Key Strategies?: https://revcycleintelligence.com/news/what-are-capitation-reimbursement-
models-key-strategies
Rice, T. (2021). Retrieved from Key Components of National Health Insurance Systems: https://www.sciencedirect.com/topics/economics-econometrics-and-finance/fee-for-service
HSS491 061222/ttb
Your preview ends here
Eager to read complete document? Join bartleby learn and gain access to the full version
- Access to all documents
- Unlimited textbook solutions
- 24/7 expert homework help