Healthcare Reimbursement Analysis

This paper presents an interpretation of payment reimbursement systems in the health care industry. Managed care is a health care delivery system that is organized to manage quality and cost utilization. A comparative overview and description of payment compensation will be given in order to understand the flow of finances in the health care industry. The focus will be on the capitation and fee-for-service reimbursement systems. Readers will then be able to conclude that the appropriate reimbursement method is reliant on upon the amount of risk a party is able to assume.

Managed care in the hospital reimbursement is a system of healthcare delivery that aims to provide a generalized structure and focus managing the use access cost quality and

Reimbursement programs are a part of the United States health care system and they represent a financial tool for providing cash flow to service physicians and hospitals. Often times, the competency to provide quality health care is to be contingent on the payment for the services given by physicians and hospitals. Physicians that take part in the managed care systems are reimbursed by several different methods for their services. The two most common methods are Fee-For-Service or Capitation. Managed health care has grown considerably within the health care industry and Physicians have faced several challenges in establishing and financing payment systems for services. On the daily in the news you will see or hear about the financial savings resulting from managed health care as well as the restrictions on patient freedom. Insurance risk seems to be one of the less talked about concerns in the movement toward providing health care and professionals often ponder about who should bear the risk of insurance fees. For providers reimbursement is an essential portion of the managed care system. In order for them to receive their incentives to provide that efficient quality care they need to be reimbursed

This is used in our office on patients that have had surgery, they are covered for 90days post op. unless their insurance says deems that they have a copay for x-rays.

Contact capitation- is similar to the capitation model, but has added structure where the physician is paid a set fee for initial visit and then they are responsible for follow up care for a period of 6-12 months. If they patient decides to go elsewhere for services then that provider will lose payment.

Physician DRG – this is a reimbursement method where the physician is paid on a diagnosis related group. Which is under development for many hospitals to be paid the same way. Hospitals receive the saving when they are able to make the hospital length of stay less, and the same goes for the physician, if they are able to provide more efficient care to the patient.

Fee incentive methodology- a flat fee method to set a change in the physician’s behaviors of treatment. This method urges physicians to work in a manner that is more for the patient and does not affect the