Reimbursement Issues in Healthcare

Third-Party Payment Systems:
a) Healthcare System Reimbursement: Evaluate third-party payer models for the impacts they present on healthcare system reimbursement.
Third-party payer models currently have a tremendous impact on the healthcare reimbursement system. The most considerable of these is the diverse forms in which they cause reimbursement to manifest. The vast majority of patients involved in the healthcare system utilize third-party payer models in the form of healthcare insurance. Insurance companies are the predominant means of reimbursing healthcare organizations for the services they provide, the equipment they use, and the staff they employee. In a sense these insurance companies are reimbursed by the premiums they exact from their patients. These two aspects of reimbursement make this concept multidimensional, which is the main effect of third-party payer models on healthcare system reimbursement.
b) Reporting Requirements: Analyze the reporting guidelines of third-party payer payment systems.
There are several challenges and opportunities for third-party payers regarding reporting guidelines for their payment systems. The most substantial challenge is to have payment data integrated, accessible, and available for reports in an expedient time frame to increase transparency within organizations and throughout this industry (Disparte, 2017). The tendency of most organizations is to build data silos for each regulatory report. Those that are able to meet this challenge with an integrated form of organizing and storing such data are able to gain an opportunity to reuse this data for additional reports. Thus, the opportunity then becomes one based on decreasing time to action by simply reusing data pertinent for multiple reports. Additional challenges are related to successfully protecting such data with established governance policies and security measures.
c) Compliance Standards and Financial Principles: Analyze how healthcare organizations in general utilize financial principles to guide strategic planning to ensure the meeting of third-party submission requirements.
There are a couple of basic staples of financial principles which healthcare organizations routinely leverage to guide strategic planning to meet third-party submission requirements for regulatory compliance. The most eminent is maintaining a propitious balance between revenues and expenses. Preserving such a balance is a critical facet of operations and an area in which the former regularly intersects with finance. There are also various facets of accounting deployed which help to maintain the foregoing goal. Accruing accounting is an accounting method whereby expenses and revenues are charged to the year they apply (Needleman, 2003), which is not always the same year in which they occur. This accounting method and focusing on a favorable balance between revenues and expense is critical to strategic planning for third-party healthcare payers.
d) Reimbursement Methods: Considering third-party payer systems, what strategies would you recommend organizations implement in order to receive full reimbursement on claims as well as to improve timeliness of this reimbursement? Be sure to justify your recommendations.
The principal strategy organizations should implement to receive full reimbursement for claims in a timely manner is to forge relationships with people in financial departments of payers. Organizations should know who is tasked with providing reimbursement and develop a working relationship with such a person to ascertain the relevant scheduling and administrative processes for payment. Doing so will enable organizations to know who is responsible for reimbursement issues and what is required to preemptively mitigate any issues. It would also help to have relationships with people working in collections in case of any prolonged dilatory measures on the part of payers.
Operational and Strategic Planning in Healthcare:
a) Pay-For-Performance Incentives: Based on your prior analysis of the impact of case rates and management utilization data on pay-for-performance
incentives, recommend appropriate operational strategies to improve performance measures that will maximize reimbursement. Be sure to provide
support for your recommendations
The main operational strategy this author recommends is to take a data-centered approach to operations. Thus, all data should be stored securely in adherence to well defined governance protocols that decrease time spent retrieving, curating, and validating data. To this end organizations should leverage cloud infrastructure in which they only pay for the data services that they actually use. Organizations should also seek ways to utilize intelligent solutions (involving facets of machine learning and Artificial Intelligence) to automate and expedite workflows, particularly for repeatable, necessary tasks related to reimbursement. Most importantly, organizations should leverage these techniques for network optimization related to reimbursement. These options can provide real-time analysis of networks to maximize efficiency (Harper, 2017).
b) Operational Performance Measures: Considering benchmarking data, recommend performance measures that should be monitored for the purpose
of maximizing reimbursement.
Performance measures that should be monitored for maximizing reimbursement include the timeliness of remuneration payments. Organizations should track when each client pays them. Moreover, they should also monitor the method of payment and when that payment occurs. Additional performance measures include tracking how swiftly invoices are produced and generating them at specified intervals. Moreover, performance measures include the bureaucracy of the accuracy of filing claims, denoting to what extent required medical procedures were completed, and determining the data quality of the data input to streamline the overall process.
c) Teamwork and Strategic Planning: Recommend collaborative teamwork principles that would be beneficial for healthcare strategic planning in terms
of reimbursement. Be sure to provide support for your recommendations.
One of the first principles that is beneficial for healthcare strategic planning in terms of reimbursement is aim for shared goals (Mitchell et al, 2012, p. 6). Thus, reimbursement should not simply be a concern for those in back offices or in administrative positions. All members of a healthcare team should become aware of what is required to achieve reimbursement goals and take a shared sense of ownership in achieving them. Every team member in a different position should understand how reimbursement affects his or her job, from practitioners to human resources professionals. Additionally, organizations should have clear roles for various team members. The clarity of those roles should extend beyond simply being a part of a team but also include how those roles can impact the reimbursement process. Those roles then each come a separate yet interrelated series of responsibilities, job functions, and accountability for achieving goals for reimbursement.
d) Communicating Strategic Planning Across Teams: What types of tools or strategies would you recommend for communicating strategic planning
conclusions to key stakeholders, members of cross-disciplinary teams, and the rest of the organization? In other words, how would you communicate strategic planning information to clinical vs. non-clinical staff? To administrative staff? Be sure to provide support for your recommendations.
Communicating strategies to key stakeholders would require group meetings. Clinical staff should gather together to share a discussion about how they can positively implement a particular strategy for a healthcare organization. This way those in various roles can contribute to the discussion to maximize strategic implementation. Those in clinical roles must actuate such strategy specifically as it relates to the general public, so they should have input in how such strategic measures are implemented. Non-clinical staff has less of a role in strategic implementations so it should receive email notifications about strategic measures. Administrative staff would benefit from similar email notifications, which would give them a comprehensive overview of the strategic trajectory.
e) Financial and Reimbursement Strategies: Considering cash flow and days in accounts receivable of hospital and health systems, recommend reimbursement strategies that would be appropriate for low- and high-performing health systems. Provide evidence to support your conclusion
Appropriate reimbursement strategies for low performing hospital and health systems include late fees that are a percentage of the amount owed. Such fees should spur these facilities to expedite the reimbursement process. It is also apropos to issue written reminders for the purpose of remuneration. Moreover, these reminders should be proactively issued in advance of the due dates for remuneration. The opposite approach is appropriate for high-performing health systems. They should receive incentives for the timely issuing of payment. These include discounts on rates and bundled packages to motivate them to continue doing business in a timely fashion for remuneration.
References
Disparte, D. (2017). Blockchain could make the insurance industry much more transparent. www.experfy.com Retrieved from https://www.experfy.com/blog/blockchain-could-make-the-insurance-industry-much-more-transparent
Harper, J. (2017). The Horizontal Impact of Advanced Machine Learning: Network Optimization. Retreived from https://analyticsweek.com/content/horizontal-impact-advanced-machine-learning-network-optimization/
Mitchell, P., Wynia, M., Golden, R., McNellis, B., Okun, S., Webb, C.E., Rohrbach, V., Von Kohorn, I. (2012). Core principles & values of effective team-based healthcare. www.nationalhec.org Retrieved from https://www.nationalahec.org/pdfs/VSRT-Team-Based-Care-Principles-Values.pdf
Needleman, J. (2003). Assessing the financial health of hospitals. https://archive.ahrq.gov/ Retrieved from https://archive.ahrq.gov/data/safetynet/needleman2.htm#references