Lecture for an Introductory Health Care Finance
Different studies have a diverse definition of the phrase Healthcare Finance. According to this article, Healthcare finance is defined as the process of healthcare organizations mobilizing, accumulating, and allocating funding to address the health needs of people (individual or collectively) (Reiter & Song, 2018). Studies emphasize that the purpose of healthcare finance is to make funding accessible and ensure that appropriate financial incentives are provided to guarantee that individuals have access to efficient public health and individual care (Johnston & Mumtaz, 2018). This paper aims to define and evaluate the three phases of health finance, which include; Medicaid, Medicare, and Managed Care, which is developed to enhance patient quality care.
Medicaid
Medicaid is an essential scheme that is developed to recompence for health care for people who cannot pay for efficient healthcare. Knowing the compensation process can be a bit complex. As a care provider, it is essential to understand the process and requirements obliged by Medicaid (Casper et al., 2019). According to different studies, Medicaid reimbursement approaches are known to alter. The Medicaid reimbursement method is dependent on various factors, but several aspects remain relatively general. The Medicaid reimbursement approach incorporates two models these include; the Fee-For-Service model and the Managed Care Model.
Under the Fee-For-Service (FFS) approach, every service provided receives an accurate compensation for the care service provided. FFS charges are structured to recompence physicians only for the service that a patient has been delivered (Grabowski, 2019). Inopportunely, this exchange is not beneficial for the physicians as working with patients who carry personal cover. The FFS reimbursement approach is directly divergent to the Managed Care technique.
Currently, a significant number of countries prefer Managed Care Services to administer Medicaid expenditure. Nearly seventy percent of Medicaid receipts are presently registered in Medicaid managed care services (Grabowski, 2019). Research indicates that through managed care services, an individual is regarded as “a whole” through distinct services. It signifies that regardless of the services the patient receives, Medicaid reimburses the exact expanse (Casper et al., 2019). The amount is then divided aligning with the services received. The care providers can earn more for every service if a patient has received a minimum amount of services. If they received I higher sum of services, the care providers would collect less per service.
Reimbursement Process
Comprehending the Medicaid arrangement, where the cash originates, and its reimbursements are the most complicated parts. Many physicians choose not to implement Medicaid due to these difficulties (Gordon et al., 2018). Under Medicaid, the process of reimbursement varies depending on the model implemented by nations (Casper et al., 2019). For the FFS approach, naturally, the state’s Medical Assistance scheme compensates care providers an average charge for a specific health service. The government recompences the Managed Care Organization (MCO) for a capitated amount (per month, per individual reimbursement irrespective of the care provided). Medicaid reimbursement process is associated with low prices, long waiting times, and increased paperwork.
Steps Taken to Receive Reimbursement
There are various steps that a provider should consider when billing Medicaid for the services they have provided. The first step to receiving reimbursement is by providing appropriate documentation and diagnoses of the service they rendered alongside their billing record. For medical providers to be reimbursed, they are obliged to forward a claim form that indicates the type of treatment they have offered to the insured. According to experts, there is a service code for every significant form of service. The service provided should be billed with the correct service code. The Healthcare Common Procedure Coding system gives the service code. If the service code is unclear for a significant form of service, it is advised to confirm with the Medicaid.
The complexity of Each Step
The significant complexity of Medicaid reimbursement is the physician’s uncertainty of the service codes. Studies indicate that Medicaid reimbursement alters from nation-to-nation. Every nation has a reimbursement rate. This presents issues to the reimbursement procedures since some physicians dont have accurate information concerning the altering reimbursement rate. For this reason, care providers are obliged to accept the reimbursement rate set by Medicaid and cannot charge the patients additional fees.
Nature of Information Required from Each Organization
Studies indicate that for healthcare organizations to have a successful reimbursement process, they have to ensure that the revenue cycle is administered appropriately to minimize billing costs and increase collection costs (Casper et al., 2019). Organizations need to comprehend this information during the period of enhancing provider consolidation. Healthcare organizations should be acquiring and affiliating with independent approaches (Casper et al., 2019). According to research, the quality of the reimbursement cycle depends on the linkage between individuals, procedures, and infrastructure. , administrators are tasked to recognize the standard to which they want to manage professional revenue cycle activities.
How Long It Takes to Receive Reimbursement
Typically, Medicaidreimbursment takes up to 90 days to process a medical expense claim. Regularly, this procedure takes longer since the care provider does not send bills on a timely basis.
Benefits of Medicaid to Both Healthcare Organizations and Patients
Medicaid reimbursement offers comprehensive coverage and financial protection for millions of individuals (Casper et al., 2019). Despite individual’s low revenue, Medicaid members experience rates of access to care comparable to those among individuals with private insurance. Moreover, to acute healthcare, Medicaid ensures expensive long-term care for many older adults with disabilities, care homes, and the community (Casper et al., 2019). Medicaid reimbursement bolters the private cover market through acting as a high-risk ground offering coverage for various uninsured individuals who are excluded from the private cover due to low revenue or disability. Medicaid plays a crucial role by supporting the low-income medicare benefactors pay for premiums and expense-sharing, and offering extended services and support.
Medicare
Medicare services incorporate four features (part A, B, C, and D) (Fang, & Gong, 2017). Part A includes inpatient institutions, skilled nursing organizations, nursing homes, hospices, and home healthcare. Under part A, providers collect Medicare recompense for hospital-based services through the Inpatient Prospective Payment System (IPPS). Part B ensures casualty and doctor-centered ambulatory services (Fang & Gong, 2017). Part C, also identified as Medicare Advantage, offers prescriptions, vision, and dental that is not accessible under standard Medicare guidelines. Part D utilizes old-style Medicare since it practices a private prescription plan to administer charitable prescription drug benefits (Fang, & Gong, 2017). Moreover, part D supplement either Medicare Advantage or traditional Medicare.
Studies define Medicare as a health cover scheme that principally covers individuals aged 65 and above and incapacitated people who succeed for Social Security (Ridley & Lee, 2019). Despite revenue, individuals who are 65 can register in Medicare if they remunerated into Medicare/Social Security resources. Under Medicare, coverage is exact for Medicaid, ensuring process and emergency care, hospice, smoking termination program, and family planning with limited vision and dental coverage. Hayward (2016) states that Part A of Medicare costs nothing for people who have paid Medicare levies for the past ten years. Part B budgets approximately $104.90 per month in most care institutions. Part D costs roughly $30 monthly (Ridley & Lee, 2019). Medicare Advantage expenses can alter. The scheme is administered and subsidized by employees’ taxes, interest received on trust fund savings, and Medicare rewards.
Reimbursement process
Medicare settlement incorporates the payments healthcare institutions, and physicians receive for the services offered to patients covered under Medicare (Gupta et al., 2017). The compensation is forwarded to the billing department, where providers can decide to accept the amount that Medicare has set for the care they have offered. According to studies, Medicare pays eighty percent of the total costs.
Moreover, this reimbursement procedure is primarily funded through payroll taxes gathered by the Federal Insurance Contribution Act (FICA) and the Self-Employment Contributions Act (SECA). Governments use the money to reimburse physicians, hospitals, and private insurance organizations (Mahendraratnam, Dusetzina, & Farley, 2017). Additionally, funding for Medicare Services originates from bonuses, deductibles, copays, and coinsurance.
Steps Taken to Receive Reimbursement
According to studies, Medicare reimbursement should be filed no late than 12 months after the date when the service was provided. Individuals are advised to consult their providers to assist in filling the Patient Request for Medical Payment (CMS-1490S) Form. Moreover, the individual should ask for an itemized bill for their medical therapy. An Individual’s itemized bill for therapy proves their claim’s validity (Fang & Gong, 2017). Individuals are obliged to make sure that their itemized bill incorporates they date of treatment, Place the individual received care, physician name, description of every medical or surgical therapy reviewed and its chargers, and significant diagnosis. The individual should include a supporting attachment to their claim (Fang & Gong, 2017). These documents should incorporate referrals to specialists and information on the individual’s medical history. All applications should be submitted via mail since claims cant be made online.
The complexity of Each Step
Medicare reimbursement obliges individuals to file a claim within 12 months after treatment. This factor presents complexities since some patients may fail to submit the request within 12 months for various reasons (Fang & Gong, 2017). Medicare reimbursement requires individuals to have precise information concerning their treatment procedure and physician details. On most occasions, patients experience difficulties in recording this information since they are not sure.
Nature of Information Required from Each Organization
Research indicates that Medicare reimbursement obliges organizations to focus on individuals that consistently pay below the Medicare scheduled charges (Fang & Gong, 2017). Moreover, these organizations are expected to develop a value proposition, incorporate coders and maintain minimum ancillary services
How Long It Takes to Receive Reimbursement
Medicare reimbursement process takes at least 60 days to process a reimbursement claim. If individuals have not paid the physician, they should communicate with the doctors to prevent black marks on their credit. However, Medicare claims to physicians take approximately 30 days to process (Mahendraratnam et al., 2017).
Benefits of Medicare to Both Healthcare Organizations and Patients
Medicare assists individuals in maintaining health. The scheme offers essential preventive services and screening at no expense. Part B of Medicare provides a yearly free health checkup and periodic testing for cardiovascular illnesses (Mahendraratnam et al., 2017). Part D of Medicare assists individuals in paying for expensive prescription drugs. It is no doubt that Medicare plays a crucial role in the fight against poverty. For the terminally sick, this program provides a hospice benefit that assists individuals to get compassionate, end-of-life treatment at their place. Medicare pays doctors and organizations for quality treatment rather than the number of services. The program is endorsing got improved delivery of care, with approaches to enhance care quality and coordination, prevent readmissions from caring settings and minimize infections attained during a hospital stay.
Managed care
Many countries have included managed care into their Medicaid programs due to various reasons. According to research, managed care offers nations some control and predictability cover future expenses. Contrasted to FFS, managed creates room for enhanced liability for results and can support efficient approaches to evaluate, report, and observe performance, access, and superiority (Mahendraratnam et al., 2017). Moreover, managed care programs present an opportunity for enhanced care administration and care management. Managed care approaches are known to alter depending on the state laws. Managed care utilizes three aspects to deliver quality services these include;
Comprehensive-risk based managed care
In this aspect, governments bond with managed care plans to insure most Medicaid amenities for Medicaid individuals. These plans are reimbursed with a tax rate and a fixed sum per member every month to cover a significant type of service (Mahendraratnam et al., 2017). Different Medicaid managed care schemes have more than on benefit, such as character health services, oral care services, nonemergency transfer are curved out and provided separately by FFS.
Primary Care Case Management (PCCM)
Enrollees of this scheme have selected a primary healthcare provider who is reimbursed monthly to shoulder accountability for administering and synchronizing their primary healthcare (Mahendraratnam et al., 2017). Care providers are not at monetary risk in these preparations and remain to be reimbursed by FFS.
Limited benefits strategy
Different countries prefer limited-benefit structures to administer precise benefits and offer services for a significant subpopulation (Mahendraratnam et al., 2017). These often include inpatient psychological health or combined mental health, and substance misuse inpatient supervision, among others.
Steps Taken to Receive Reimbursement
The first step is to document the information essential for reimbursement (Mahendraratnam et al., 2017). Care providers log into the EHR and record vital information concerning the patient’s history and present complexities. After recording the data in EHR, certified coders assign medical codes in the EHR. These codes reflect narrative documentation into precise terms that payers utilize to comprehend what services to provide and why (Mahendraratnam et al., 2017). This incorporates the International Classification of Diseases (ICD)-10 codes. After assigning codes, the claim is submitted electronically to payers to identify possible errors. The next step is interpreting the payer’s feedback. At this step, payers review the application and adjust where possible. The last step is preparing for post-payments audits (Mahendraratnam et al., 2017). At this stage, providers need to contend with post-payment inspections, which payers request documentation to guarantee accurate reimbursement.
The complexity of Each Step
Each of these steps is time and resources consuming. For instance, documentation takes time since providers and patients are obliged to have accurate information. Moreover, assigning codes is another complicated step that requires accuracy. Providers need to be sure of the coding to avoid errors and enhance care.
Nature of Information Required from Each Organization
Managed care contracts should incorporate language that requires the participating provider to comply with all rules, bylaws, and procedures of MCO and its different structures (Mahendraratnam et al., 2017). The provider is expected to obtain and carefully review a copy of all materials to guarantee consistency with the organization’s operating process. Organizations are obliged to predict future alterations to address various needs accurately.
How Long It Takes to Receive Reimbursement
According to different medical studies, the managed care reimbursement process takes up to 60-90 days (Mahendraratnam et al., 2017). Regularly, compared to Medicaid reimbursement, this procedure takes longer since the care provider does not send out bills on a timely basis.
Benefits of Managed Care to Both Healthcare Organizations and Patients
There are different benefits achieved through managed care. This includes, individuals having multiple choices for coverage and paying minimum cost for prescription drug. Managed care helps the patient receive treatment of their choice as well as reduce the costs of medicines.
Conclusion
Medicaid compensation is parallel to Medicare, given that the reimbursement goes to the care provider. Nevertheless, physicians who preferer Medicaid services are obliged to receive the reward offered by Medicaid as revenue for services provided. Medicaid does not make payments to entities but works in a scheme that sends money to the providers. Governments are known to be ones making the payments. Finding a physician who accepts Medicare or Medicaid can be sophisticated, pending with the location. Moreover, care insurance obliges physicians to recognize the different rates concerning reimbursement of Medicare and Medicaid.
References
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