Sign Up Now
Get instant access to over 1 million+ study documents
OR
Already registered? click here to login
By creating your account, you agree to our terms of service, privacy policy and student honor code.
Reimbursement
Payment for healthcare services is one of the issues that has been the subject of numerous debates and most reformed aspects of the healthcare sector in the United States. This issue has attracted considerable attention because of the increased focus on enhancing the affordability of healthcare services without compromising quality. Consequently, various reimbursement models have been established to help address how providers are paid. There are many types of payers responsible for reimbursement as few patients usually can or do pay for their healthcare services privately. According to Donnelly et al. (2019), the different types of payers can be classified into three i.e. single-payer, multiple-payer, and state-based financing. Multiple payer refers to a health sector financed by various entities including the government and private health insurance.
In the scenario referenced in Topic 8, the type of payer responsible for reimbursement is a public payer funded by the federal or state government. Medicaid is an example of a taxpayer-funded or public payer that would be responsible for reimbursement of healthcare services for this patient. Medicaid has undergone reforms and changes in recent years, which have resulted in the expansion of the program. Lee et al. (2020) state that Medicaid expansion has positive impacts on self-reported diabetes management. The patient’s history of type 2 diabetes and age makes him ideal for Medicaid payment of care services.
While Medicaid program would be responsible for reimbursement for this patient, a reimbursement claim could be denied by this payer. If the denial is unjustifiable, there are various steps that can be undertaken to appeal within a 90-day period. The first step would entail writing an appeal letter in which the item under appeal is cited and an explanation of why the Medicaid decision is wrong. The next step is to prepare for the appeal hearing once the date is set and appearing in person or asking for representation by an attorney.
References
Donnolley, P.D., Erwin, P.C., Fox, D.M. & Grogan, C. (2019, November). Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section. American Journal of Public Health, 109(11), 1482-1483.
Lee, J., Callaghan, T., Ory, M., Zhao, H. & Bolin, J.N. (2020, May). The Impact of Medicaid Expansion on Diabetes Management. Diabetes Care, 43(5), 1094-1101. Retrieved from https://care.diabetesjournals.org/content/43/5/1094
Health Care Economics In economics, cost-benefit analysis assists in evaluating the costs of an approach in terms of resources spent while cost-effective analysis evaluates the costs as achieving some sort of benefit which is not evaluated in monetary terms. Moreover, cost-benefit study examines several aspects including net-present value, present value of benefit, and present value of costs; in line with this, if a project indicates that the monetary outcome is greater
Health Care in the U.S. And Spain What Can the U.S. Learn About Health Care from Spain? In 2009, Spain's single-payer health care system was ranked the seventh best in the world by the World Health Organization (Socolovsky, 2009). By comparison, the U.S. health care system ranted at 37 (Satiroglou, 2009). The Spanish system offers coverage as a right of citizenship that is constitutionally guaranteed. Spanish residents pay no expenses out-of-pocket, with
Health Care Economics Medical Care is never free, although the individual may pay nothing? Medical Care is both a commodity and a service. The process of consuming medical care has a cost, even if the after insurance price is zero to the consumer. For instance, there are hard costs that include the buildings, equipment and supplies that house the medical care or office. There are the wages that are paid for the
This is being done by disseminating and using practice guidelines for various medical conditions and by profiling individual physicians' provision rates. Demand side cost sharing is where patients must contribute more to their healthcare by paying more in copayments and deductibles. One recent advance in health care financing is the health savings account (HSA). These plans rely heavily on patient cost-sharing. An HSA basically provides health insurance along with a
Healthcare Organization and Finance Scenario Medicare covers healthcare services such as surgeries, laboratory testing and doctor visits. It also covers supplies such as walkers and wheelchairs. These services and supplies must be considered as indispensable in the treatment of a certain disease or condition (King, 2009). Therefore, the expenses related to the walker that was prescribed to Mrs. Zwick after her discharge would be fully met in this section of the Medicare. Essentially,
Specialist doctors will normally examine only those patients who have been referred to their clinic by a general practitioner. (U.S. Department of State, n. d.) The Government of Netherlands is not responsible or the ongoing management of the healthcare system on a daily basis which is offered by private healthcare service providers. However the government is charged with the accessibility and ensuring appropriate standards of the healthcare. A new healthcare