Third-Party Payment Systems and the Operational and Strategic Planning

IV. Third-Party Payment Systems:
1. a) Healthcare System Reimbursement: Evaluate third-party payer models for the impacts they present on healthcare system reimbursement.
Third-party payment has had a major impact in healthcare system through the aspect of increased demand and in so doing driven up prices. In particular, medical suppliers that deal with comparatively low levels of third-party payment have experienced considerably lower price upsurges in the course of time. The Patient Protection and Affordable Care Act (PPACA) has augmented the practice of high-deductible insurance, but has other features that work against cost suppression and control. In addition, the third-party payer models have also facilitated faster and easier payment practices for healthcare services rendered (Buff and Terrell, 2014).
2. b) Reporting Requirements: Analyze the reporting guidelines of third-party payer payment systems. What opportunities and challenges do they present for healthcare leaders in meeting reporting requirements?
There are opportunities presented to healthcare leaders is that there is the ability of fast, comprehensive assessment of prospective misconduct of corporate officers who can influence billing decisions. There is the quick detection as well as reporting and this diminishes the loss incurred by third-party payers from false claims. In addition, it is possible to augment the structure of the billing of the corporation’s operations and consistency between different business units. There are also challenges that come about. One of the challenges takes into account the fear and hesitation be personnel in reporting any issues and problems that come about. In addition, having a centralized system can limit the effectiveness of the payment systems in different units (Office of Inspector General, 1998).
3. 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.
One of the ways is to ensure that the emphasis is shifted from the products and services rendered to the client. The focus is on how the services are transmitted to the client and their experience. What matters is patient satisfaction. Another aspect is being compliant to the set rules and regulations to ensure that when requests are made, they have complied and adhered to the regulations agreed upon (Perera and Peiro, 2012).
4. 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.
One of the strategies is episode-of-care payment which makes it possible for providers to delineate a single, wide-ranging price for an episode of care, which as a result would facilitate payers to have faster and quicker perception of the complete cost of treatment and to more precisely match the costs of dissimilar providers that could provide the same treatment (Olsen et al., 2010). Bundled payment is another strategy and is beneficial because its execution does not necessitate any form of organizational change to the delivery system; it would basically necessitate an act of collaboration in the prevailing system (Olsen et al., 2010). 
V. Operational and Strategic Planning in Healthcare:
1. 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 following are suitable operational strategies to enhance performance measures:
i. Integrating care delivery systems: To achieve spot-on system integration, organizations must contend with four associated groups of choices including describing the scope of services, focused volume in smaller number of localities, selecting the correct location for every service line, and assimilating care for patients through all locations. This makes it possible to attain proper performance measures
ii. Analyzing results against targets: It becomes possible to assess the performance of a personnel and also that of the reimbursement system in overall if the actual results are examined against the originally set targets to determine whether they are below par or above par (Porter and Lee, 2013).
2. b) Operational Performance Measures: Considering benchmarking data, recommend performance measures that should be monitored for the purpose of maximizing reimbursement.
Operations performance measurement, in this regard, measures progress toward meeting the objectives of reimbursement system management and operations. One of the measures encompasses outcome measures, which takes into account whether the outcomes being accomplished are within the target range and whether they are being enhanced in time. Another measure is utilization performance measures. This takes into account whether the resources are being utilized suitably. This can include rates of readmission, prescription rates as well as formulary compliance. Process measures are also included in assessing whether the suitable tests are being conducted or irrelevant ones are being done (McKesson, 2017).
3. 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
Collaborative teamwork increasingly predominant, backed by policies and practices that convey care faster to the patient and defy outdated professional limitations. There are different principles that would be helpful in healthcare strategic planning with regard to reimbursement:
i. Good communication: Having a “two-way” communication makes it easier for the organizations as well as the payers to come up with a suitable and beneficial form of reimbursement.
ii. Respecting roles: All members of the team should have roles that are well outlined and every one of them ought to be respected as well as having an understanding of the manner in which the roles have the potential to impact reimbursement.
iii. Quality and outcomes: Guaranteeing the quality and outcomes are acknowledged as a significant element of a good team and contains numerous reflective tools both internal and external to the team. These two elements are imperative for accomplishing effectiveness and to meet their targets.
iv. Appropriate team processes and resources: This takes into account accessibility to adequate physical resources, discretion to make personal actions, suitable and well-organized systems and procedures, comprising initiation procedures, guidelines, and book-keeping that serves the need of the service and at the same time evading duplication (Nancarrow et al., 2013).
4. 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.
An emphasis on communication is pivotal to the mission of patient care, dedication to quality, transparency as well as professional reputation. This encompasses engaging both clinical and non-clinical parties. One of the tools and approaches is feedback and coaching. For instance, both the clinical and non-clinical staff as well as administrative personnel can be questioned on what is working and what is not. In addition communication with individuals from different departments to provide feedback, recommendations and also coaching. Another approach for outlining strategic planning encompasses job description as well as expectations. Though this approach it becomes possible to associate the individual’s job to the overall plan. For instance, the manager should define the overall strategy as that of patient care as this facilitates the perception of stakeholder importance to the eventual mission and strategic plan (Leebov, 2017).



References
Buff, M. J., & Terrell, T. D. (2014). The role of third-party payers in medical cost increases. Journal of American Physicians and Surgeons, 19(2).
Leebov, W. (2017). Team Collaboration and Communication: Engaging Non-Clinical Employees Who Don’t Deal Directly with Patients. Language of Caring. Retrieved from: http://www.languageofcaring.com/resource/team-collaboration-and-communication-engaging-non-clinical-employees-who-dont-deal-directly-with-patients-2/
McKesson. (2017). The Pay for Performance Model of Healthcare Reimbursement. Retrieved from: http://www.mckesson.com/population-health-management/resources/pay-for-performance-model/
Nancarrow, S. A., Booth, A., Ariss, S., Smith, T., Enderby, P., & Roots, A. (2013). Ten principles of good interdisciplinary team work. Human resources for Health, 11(1), 19.
Office of Inspector General. (1998). Compliance Guidelines. Retrieved from: https://oig.hhs.gov/fraud/docs/complianceguidance/thirdparty.pdf
Olsen, L., Saunders, R. S., & Yong, P. L. (Eds.). (2010). The healthcare imperative: lowering costs and improving outcomes: workshop series summary. National Academies Press.
Perera, F. D. P. R., & Peiró, M. (2012). Strategic planning in healthcare organizations. Revista Española de Cardiología (English Edition), 65(8), 749-754.
Porter, M.E., Lee, T. H. (2013). The Strategy That Will Fix Health Care. Harvard Business Review.