Hcm400 Provider Payment Paper

The Inpatient Prospective Payment System is based on CMS (Medicare) standards because it is the largest reimburser. It was created to control rising healthcare costs by determining reimbursement prospectively. The costs of inpatient acute hospitals stays under Medicare Part A are fixed so that each patient case aligns with a Diagnosis Related Group (DRG).

The reimbursement method used at St. Anthony’s hospital is quite distinct depending on the party doing the payments. Payments are received from Medicare, Medicaid, private insurers and also directly from patients. The party responsible for Medicare payment is the Federal government and it offers payment mainly for the elderly. With the Medicare payment, hospitals receive a flat fee depending on the case. According to Gee (2006), most hospital revenue has declined because of the revised payment set by the Diagnosis-Related Groupings. The fee for most cases varies according to the Diagnosis-Related Group (DRG) it can be classified under. For example, Medicare pays only a fixed amount for an elderly patient suffering from pneumonia regardless

The fee-schedule is the second component of the payment-determination basis, in which fees are pre-negotiated and have no correlation with the provider’s cost. For example, Medicare uses a fee schedule to

The healthcare system in each country is intended to meet the best possible medical services needs of its citizens. One country’s healthcare system can vary from another. This is according to their administration strategy, training, education, technology, and spending plan. Social, economic, political, and physical parts of the nation also play huge role in defining a country’s healthcare system. There are many similarities in the delivery of medical services between United States and Nepal. For the middle class people, affording a good healthcare system is still an unresolved issue of these two countries. The issue of financing the system of healthcare has been the biggest challenge to the government of Nepal, and it is similar to the Medicare and Medicaid programs in the United States. Although Nepal and the United States have similarities in healthcare system, they also equally share significant differences in providers, spending and the medical professionals. Some people consider that the healthcare system in the U.S. is superior.

A mixed payment system combined with physician monitoring, will provide physicians with incentives to consider costs and benefits of different treatment options, which will lead to an efficient level and quality of care. (1,2)

Pay-for-performance payment model – healthcare payment systems that offer financial rewards to providers who achieve, improve or excel their performance on specified quality of care and cost measures (HealthCare Incentives Improvement Institute, N.D.)

Healthcare reimbursement systems within the United States are a complex structure for obtaining payment for services rendered. The healthcare system officers are required to understand the ordinary principles of the payer system. Understanding the rules, and keeping up with the continuous changes will allow the providers, physicians, and facilities to gain an advantage in this growing healthcare domain. Both private and commercial insurance companies provide a diverse menu of choices to customers. All third-party payers create interest in decreasing healthcare costs and improve control access to the not needed services. This paper will address the complexity of the healthcare reimbursement systems in the United States. Additionally, the research

In 1983, the Medicare prospective payment program was implemented which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007). To keep the costs below the diagnosis related payment, hospitals had to manage efficiently the treatment provided to a client and reduce the client’s length of stay (Jacob & Cherry, 2007). Case management, or internal case management “within the walls” of the health care facilities was created to streamline costs while maintaining quality care (Jacob & Cherry, 2007).

Fee for service, as the name suggest is a method in which the healthcare provider is paid individually for each and every service provided. In this method the numbers of services determine the amount of reimbursement. This is where the healthcare providers misuse their authority and either provides more services than what is needed or just manipulate the number of services provided. There are specific

Develop payment strategies to reduce unwarranted price variation, such as reference or value pricing (e.g., analysis of price variation among network providers by procedure and service types, pilot value pricing programs,

Health care systems are different in every country around the world. There are four main components that complete a health care delivery system, described by Shi and Singh (2015) as the quad-function model, which includes insurance, financing, payment and delivery of care (p. 5). Along with the components of the quad-function model it is important to analyze a countries access to care, their health outcomes and how public health is integrated into the health care delivery system. The United States has a unique health care system that is like no other country. Great Britian, in contrast, also has a unique system that is very different than the United States.

Providing healthcare coverage to all citizens can be challenging to many countries and only the most developed countries have adequate resources to truly provide universal coverage to their citizens. Still, when coverage and resources are not sufficient, care is rationed through limited supply or limited access. Most countries have mechanisms in place, however, to insure that affordability does not limit access to necessary services.

This rewards quantity over quality. Fee for service does nothing to promote low cost, high value services, such as preventive care or patient education even if they could considerably enhance patients’ physical condition and reduce health care costs through the system. 78% of employer sponsored health insurance is was fee for service. Reimbursement is the form of payment for services provided. The most common practice is the insurance company pays to the provider directly. Under the MCO when receiving care the patient is usually required to pay a small amount out of pocket such as 15 or 20 dollars and the rest is picked up by the managed care plan.

One of the major problems facing our country today is the healthcare crisis. The inequality in our current healthcare system has created a huge gap in the difference between the level and the quality of healthcare that different people receive. Having an improved and reliable health care system available for everyone should be a priority that the government must make available. There are countries whose health care system meets the needs of the patients while there are countries whose health care systems need a great amount of overhaul for them to be able to attend to their patients. In this essay I will discuss the healthcare crisis and the differences in many countries

Under payment, an ideal healthcare system will have the challenge of delivering higher quality for lower costs. The system’s payment reform will involve a transition from fee-for-service to global from systems that are value-based important for the achievement of the overall healthcare goals. An ideal healthcare payment system will give a great deal of support to value-driven system of healthcare delivery (Kent, 2013). The fee-for-service payment system will be of great importance to the healthcare system as it will help control the costs of health care.