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Justify health care priorities
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Fee for Service: Another aspect of shared risk contracts is fee for service models. This is the most popular model in today’s health care society. Basically under this model, the provider is paid for each of the services provided to the patient. This is different from other health sectors because in other sectors price is based off of what the patient is willing to pay for. Unlike other sectors the fee for service model negotiates the prices between the two parties, the payers and the providers. The fee for service system is characterized by a coding system and guidelines. These codes are the CPT and ICD-9 codes. These codes determine what can and cannot be paid for and what to charge out.
Advantages:
There are clearly some positives of the fee for service payment system. This system puts and emphasis of productivity in health care. It is done by promoting the delivery of health care and capitalizing and maximizing visits to the providers. This method is also a flexible method. Meaning, that this method will still be utilized no matter what type of care is being provided to the patients. It does not matter if the patient is getting a surgery, therapy session, doesn’t matter what the size of the practice or the place of delivery.
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One con of the fee for service model it does not provide incentives for those that promote preventative care or those that provide efficient services. This model also makes it difficult to take care of cases by other ways such as email, phone or care coordination since generally all patient interaction is done personally and face to
...t them attain the services easily and at lower costs. In addition, these hospitals have the potential of managing effectively their cash flow. A fixed and proper payment system to the workers of the small health centers can m motivates them to avail quality services to the medical beneficiaries. Small hospitals can be able to have bonus payment in case they provide care in areas short of professional health. Hence, small hospital can implicate appropriately their method of payment. Conversely, there might be a risk possibility when it comes to accessing low amount due to the nature of the illness of the patients, the involvement of high cost of treatment amongst many other factors. In the vent that the overall health care costs are more than earlier anticipated, the hospital and the doctor shall receive less profits. This can have a negative impact on the hospital.
The chargemaster is an integral element of the revenue cycle. It is used in generating charges for services that are rendered to patients in real time, the absence of functioning chargemaster can result in potential collapse of the revenue cycle. Hence, the process to optimize revenue cycle must include optimizing the chargemaster and all services that is associated with it. The negative consequences of nonfunctioning chargemaster can include excessive payment/overcharging, inaccurate billing to patients; and can result in stiff penalties and fines (Bielby et al,
Fee-For-Service or Traditional Indemnity plans are uncommon but still used. Payment is rendered for services provided. Traditional Indemnity plans in general have no provider network and a patient can see a specialist without a referral. If a patient uses an FFS plan, the patient would pay the provider for medical care provided. If the medical care provided is covered by the plan. The insurance company would then reimburse the patient according to the guidelines stated in the policy or the UCR’s “Usual, Customary, and Reasonable Fees.” (“Private-Fee-For-Service Plans,” CMS.gov, 3/16/2012). Key benefits of a Traditional Indemnity or Fee-for-Service plan include no in network physicians or health care providers and the patient may see any physician or seek health care services at any healthcare facility. The patient or client can also seek treatment from a specialist without a physician referral. Fee-for-Service plans are the most flexible plans for choosing a healthcare provider and health care facility. However, Traditional
In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. This drives up costs by rewarding providers for doing more, even when it’s not needed. ACOs continue to utilize fee for service by creating incentives to be more efficient by offering bonuses when providers keep ...
...correctly with varied crowds of patients to reduce incentives to keep away from most patients is quite challenging. Finally, the effects pay-for-performance will have on the future of the health care depends on incentives with "teaching to the test" to guarantee that the affirmative objectives are not attained at an enormous price.
...lthcare system is slowly shifting from volume to value based care for quality purposes. By allowing physicians to receive payments on value over volume, patients receive quality of care and overall healthcare costs are lowered. The patients’ healthcare experience will be measured in terms of quality instead of how many appointments a physician has. Also, Medicare and Medicaid reimbursements are prompting hospitals, physicians and other healthcare organizations to make the value shifts. In response to the evolving healthcare cost, ways to reduce health care cost will be examined. When we lead towards a patient centered system organized around what patients need, everyone has better outcomes. The patient is involved in their healthcare choices and more driven in the health care arena. A value based approach can help significantly in achieving patient-centered care.
As a CSR, it has been my mission to provide customers with the individual attention that they deserve. In regards to the tiered service plan that has been proposed, this would be beneficial for the company now and over the upcoming years. We should still give all of the customers the same friendly attention that they deserve, yet the more valuable the customer is, the more individual attention they should receive. Whether we like to admit it or not we are dependent on the customers and the customers that provide increased sales for this company, should receive special attention. The tiered system approach is nothing that will be obvious to the one time customer, as they should receive the same treatment that all other one time customers receive.
There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).
The fourth key point is payment models. In order to make sure quality health care is given across the board you have to follow the money. In this section it talks about an idea of restructuring the payment scheme. Using bundled payments “offer the potential for promoting equity by redirecting resources to health care values...
reimbursement determinations. As a result, the camaraderie among physicians has developed into a more aggressive approach to impede competition (Shi & Singh, 2012). Little information is shared with patients in regards to procedures or disease control. The subjects are forced to rely on the internet for enlightenment on the scope of their illnesses (Shi & Singh, 2012). Furthermore, the U.S. health care system fails to provide adequate knowledge on billing strategies for operations and other medical practices. The cost in a free system is based on supply and demand and is known in advance of hospital admission (Shi & Singh, 2012). The need for new technology is another characteristic that is of interest when considering the health care system. Technology is often v...
Many people cannot afford to pay the monthly payments; therefore, they stop their insurance and become uninsured for months or even years. There are many ways people can pay for health care. Community Rating and Experience Rating is a very interesting way to pay for medical bills. With Community Rating, all the people who are members pay the same monthly payments. It doesn’t matter which group they are in. With Experience Rating, all the people who are members pay different premiums. The members who become ill will benefit from the members who stay healthy. It is very unique how the members benefit from each other, but it can still be a little confusing. It is important for the United States to make a payment plan everyone can afford and have health insurance
2. The twin problems of the health care industry as viewed by society are cost and access. First of all, the cost of getting health care is very high and it is getting higher each day. This has been mostly caused by the combination of high cost and an increase in quantity of services provided to the communities. The other problem involves access to health care. American enjoy limited or no access to health care. Many efforts have been done to reform this, but still but still many people are left without access to the care. These two problems are related due to the fact that if the health care industry gets to high off course people no longer will be able to have any access to it. The higher prices are, the lower access people have to it.
The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.
“Free medical services would encourage patients to practice preventive medicine and inquire about problems early when treatment will be light; currently, patients often avoid.” (Messerli)
Among them is its emphasis on productivity. Fee for service encourages the delivery of care and maximizing patient visits. As a payment mechanism, it is relatively flexible in that it can be used regardless of the size or organizational structure of a physician’s practice, the type of care provided such in clinic visit, surgery, therapy session, and the place of service such as physician’s office, nursing home, hospital, surgery center or the geographical location of care. Fee for service does support accountability for patient care, but it is often limited to the scope of the service a particular physician provides at any point in time. Although fee for service is easy to understand conceptually, it can be difficult to understand in practice. Patients may struggle to decipher the coding and nomenclature involved in billing, manage the numerous bills and explanations of benefits they might receive, and understand its application in inpatient settings, especially for lab, radiology, and anesthesia services. Because payment is limited to one provider for one interaction, fee for service does little to encourage management of care across settings and among multiple