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...
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…
