Reimbursement Options
Your Name
Assessment 2
Introduction
The goal of any reimbursement model used in the healthcare system should be to reward high-quality care and to allow the development of more operative ways of delivering care to enhance the value acquired for the resources expended. Ideally, () mentions that payment policies should not create hindrances to enhancing the quality of care. Some of the provider reimbursement options include fee-for-service, capitation, pay-for-performance, and resource-based relative value scale. The payment options for uninsured patients include Medicaid, financing options, self-pay, and charity care.
Part I – Provider Reimbursement Options
Fee-For-Service
Fee-for-service is based on the premise that healthcare professionals receive payment for each service offered and is grounded on a set of prices of each service. Examples of Fee-for-service include self-pay payments, retrospective payments, and managed care contracts. Some of the drawbacks of the fee-for-service reimbursement option include little or no incentive, limited face-to-face visits, and patients suffer the logistics. Firstly, the fee-for-service payment option provides little or no incentive to deliver effective care or prevent reductant care. Secondly, this payment model is limited to face-to-face visits and acts as a blockade to care coordination and management of health conditions. Thirdly, the fee-for-service payment option is expensive to patients, mainly those with seek treatment with long diagnostic procedures.
Capitation
Capitation is the payment a healthcare professional receives to cover all services for a target population over a span of time. It appears that amount of payment for this reimbursement has no direct connection to the amount of services offered. This reimbursement model has some drawbacks as it relates to offering comprehensive services. In the first place, the capitation payment model can increase patient’s health risks because of deferred care beyond the prepayment interval. Further, this model is not suitable for patients who are likely to have high per capita costs during the contract interval. Lastly, this reimbursement model is associated with high physician’s personal financial risk if care is complex.
Pay-for-Performance
Pay-for-performance is a payment incentive that is linked to meeting defined and measurable goals that are associated with care processes and outcomes, client experience, resource use, and other factors. This financial incentive influences reimbursement rates because funds redistributed to the healthcare facility are divided into different quality domains, which are safety, clinical care, efficiency and cost reduction, and client and provider-centered experience. With this in mind, the reimbursement rates are scored on several measures based on “enhancement” and “achievement.” In that manner, the Centers for Medicare and Medicaid Services utilizes the higher of the two scores to identify reimbursement rates.
Resource-Based Relative Value Scale or Case-Based
This reimbursement model is the way Medicare determines how much it will pay healthcare providers, based on the resource costs required to offer a Medicare-covered service. This reimbursement model is calculated using three aspects, which are physician work, practice expense, and professional insurance. Ideally, case-based payment encourages the overuse of services. This is because each case payment is based on a single flat rate per case, which makes clinicians focus on increase the number of cases treated, thus overusing the services available. An example of where this model is used is when treatment involves a comprehensive bundle of services that could be offered across different settings of care and over a defined span of time, such as allocating resources for a population of patients with diabetes.
Part 2 – Payment Options for Uninsured Patients
Identify and Explain Payment Options for Uninsured
Some of the payment options for uninsured patients include Medicaid, financial options, self-pay, and charity care. Firstly, the patient qualifies for Medicaid as long as he or she is either resident of the United States or specific qualified non-citizens like lawful permanent residents. Secondly, financial options for the uninsured include financial assistance and paying in advance. Financial assistance involves completing a written application and offer any information that is relevant to verify one’s financial information. Pay in advance involves saving the money and pay before seeking medical assistance rather than paying for it afterward. Thirdly, self-pay involves paying the healthcare services using cash, and the patient does not benefit from the discounted rates negotiated on the client’s behalf by Medicare. This means an uninsured patient who self-pay is charged a full, undiscounted rate by the healthcare system for services. Finally, the screening of a patient for charity care involves persons who are at or below 350 percent of the federal poverty level and are uninsured or insured and have high healthcare costs (). The process that I would implement to quality for a patient for charity care includes income tax returns for the past one months, unemployment income statements, and providing documentation from my state department of social services.
Conclusion
It is evident that different healthcare systems have diverse reimbursement model, which poses different distribution of risk. With the new healthcare payment models, patients are left with the decision to choose the model that they think is suitable for them. In an ideal world, the right decision for an individual patient, either insured or uninsured, should be made through an open and honest discussion with the healthcare professional.
References