NU 451 Healthcare Reimbursement Paper

Regis University NU 451 Healthcare Reimbursement Paper-Step-By-Step Guide

This guide will demonstrate how to complete the Regis University NU 451 Healthcare Reimbursement Paper assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NU 451 Healthcare Reimbursement Paper

Whether one passes or fails an academic assignment such as the Regis University NU 451 Healthcare Reimbursement Paper depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NU 451 Healthcare Reimbursement Paper

The introduction for the Regis University NU 451 Healthcare Reimbursement Paper is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NU 451 Healthcare Reimbursement Paper

After the introduction, move into the main part of the NU 451 Healthcare Reimbursement Paper assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NU 451 Healthcare Reimbursement Paper

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NU 451 Healthcare Reimbursement Paper

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Unit 4 Assessment

Healthcare Reimbursement Paper

Instructions

Healthcare is reimbursed in a variety of ways. The prospective payment method is one of those ways. This paper will be about the prospective payment method where diagnosis-related groupings (DRGs) forms the basis for payment.

Research and explain the origin, purpose, and description of DRGs.

Include what payment is based on.

Identify the benefits and problems with reimbursement via this method.

Explain how you as a nurse-manager can help manage costs and maximize your facility’s reimbursement from

DRGs.

The paper should contain an opening, a body, and a conclusion, and be 3-4 pages long.

3-4 professional references are required.

Sample Answer for NU 451 Healthcare Reimbursement Paper

Introduction

Healthcare reimbursement entails the nature of payment usually received by hospitals, diagnostic facility, healthcare provider and other healthcare entities after they have provided medical services to patients or clients. To date, various healthcare reimbursement models have been used to achieve the end. In most cases, the payer usually covers all or some of the healthcare costs while in some cases, the patient also covers part of it (Chen et al.,2020). However, in the case where a patient has no health insurance, then they have to cover all the costs for the healthcare services provided. It is important for healthcare professionals to understand the healthcare reimbursement models. Therefore, this presentation focuses on a healthcare reimbursement training.

Medicare Reimbursement

One of the reimbursement strategies currently in use is Medicare reimbursement. Medicare is mainly known to be a program for individuals of at least 65 years of age. However, it is also cover particular people below sixty five years with disabilities. The implication is that individuals below sixty five are included in the program under special considerations. While it has several parts, Medicare is has two major parts. The program has various parts such as hospital insurance, also known as part A and medical insurance, also known as part B (Duncan et al.,2020). Part A covers various aspects such as home health services, hospice care, skilled nursing facilities and inpatient hospital care. On the other hand, Part B covers durable medical equipment, physician services, and outpatient services. There are also parts C and D. Part C is known as Medicare advantage and offered by private insurance companies approved by Medicare. Part D covers prescription drug coverage through private insurance plans. These parts direct the reimbursement process.

As earlier indicated, the Medicare parts direct the reimbursement process. In part A, the healthcare organizations offering patient services are reimbursed through the prospective payment system. This system entails reception of a fixed amount for specific services offered without considering the actual costs. In part B of Medicare, the reimbursement is done on a fee-for-service basis (DeCherrie et al.,2021). This strategy involves setting a fee schedule, hence the healthcare entities are paid depending on the services they offer. However, such payment depends on coinsurance and deductibles. Part C reimbursement is based on capitated payments, meaning that the government pays an amount for a beneficiary to a private insurance. Finally part D reimbursement involves a combination of beneficiary premiums and government subsidies. As such, the government offers subsidies for drug costs for the beneficiaries.

Medicaid Reimbursement

The next reimbursement strategy is Medicaid reimbursement. This is a joint state and federal program focused on offering health insurance to people hailing from low income families or those with low incomes. The medical reimbursement used in Medicaid has for a long time been labeled as complex. It is also important to note that its not uniform but may vary from state to state (Mitchell et al.,2022). The collaboration means that the federal government sets rules which must be followed by the states, however, they are allowed to come up with aspects such as rates, benefits and eligibility criteria. The Medicaid covers various services such as mental health services, long-term care, prescription medication, physician service and hospital care.

Medicaid reimbursement operates on various reimbursement models. One of them is Fee-for-Service reimbursement. In this model, the healthcare providers usually bill Medicaid for every covered service they offer. The rates vary from state to state, and usually lower that the what is payed private insurers. The other model is managed care reimbursement which is based on a fixed monthly payment per person (Xu & Intrator, 2020). It is the responsibility of the state to negotiate contracts with the management care organizations, especially when it comes to reimbursement rates. The organization get capitated rate payments. There is also the intergovernmental transfers and upper payment limit. The intergovernmental transfer entails transfer of funds between local and state governments. On the other hand, the upper payment limit involves a cap on the amount of money the states are allowed to claim. The next is disproportionate share hospital payment which are payments used in offsetting the uncompensated care costs.

Private Insurance Reimbursement

Private insurance reimbursement involves private insurance companies. Such companies pay the healthcare providers for the medical and healthcare services offered to their members. Private insurance may be inform of family plans, individual plans or employer-sponsored group plans. There are various reimbursement model used in private insurance. One of them is Fee-for-Services where the healthcare providers bill the insurance companies for services offered to their members (Tsai et al,2019). The other model is capitation model. This model entails providers receiving a fixed monthly payment for every patient without considering the services offer to the patient. Some of the plans known for this model include managed care organizations and health maintenance organizations.

Cost, Charge and Payment

Understanding of the healthcare reimbursement as a topic requires that an individual or a professional understands various aspects. Among the is costs, charge and payment. While all the three are used in such environment, they are different and it is prudent to understand the differences. Therefore, this section focuses on costs. Cost is the actual expense that a healthcare provider incurs when offering medical and healthcare to patients. It covers various costs such as the overhead costs, and costs used for supplies, facilities, equipment and salaries (Lin et al.,2020). The costs can either be fixed or variable. The cost information is applied by the providers in resource allocation, pricing and determining how sustainable the operations are.

It is also important to understand charge and explore how different it is from cost and payment. Charge entails the amount which a healthcare provider bills a health insurance company or a patient after offering patient care services. The charges billed usually depends on the services offered and in some cases vary from one organization to the other. In most some cases, it is also influenced by the hospital’s pricing strategy and the geographical location. For along time, the charges set should not be negotiated but settled as they are by the health insurance companies or patients (Sen & Deokar, 2021). It is important to note that charge is also made after a healthcare organization or entity has offered services to a patient.

Payment is another aspect worth exploring. In reference to healthcare reimbursement, payment entails the actual amount of money given to the healthcare provider by the payer which can either be a patient or an insurance company. Depending on particular situations and factors, the payments transferred from the payer can either be more than, equal to or lower than the charges (Sen & Deokar, 2021). Payment in such a context may be influenced by various factors. One of such factors is seeking services out of network providers. Such cases may see the patient covering a bigger share of the costs. It is also impacted by patient agreements as stated in the plans such as terms to deal with coinsurance, deductibles and copayments. The payment may also change depending on whether the rates have been negotiated or not

Diagnostic Related Groups

It is also important to explore diagnostic related groups in relationship to healthcare reimbursement. Diagnostic related groups refer to a classification system applied in categorization and reimbursement of inpatient services offered by hospitals. It is important to note that such reimbursements is based on the patient’s age, the nature of procedure carried out, and the patient’s diagnosis, whether secondary, primary or both. This classification is majorly focused on standardization of payments for the services offered (Maryati et al.,2021). The implication is that the diagnostic related groups fosters consistent and fair reimbursement. DRGs work by classifying the inpatient hospital admissions into various groups. Such groups are usually assigned specific codes which align with a particular payment rate. As such, healthcare organizations get a predetermined payment for every patient depending on the assigned diagnostic related groups without considering the actual costs used when services were being offered to the patient

Examples of Diagnostic Related Groups

There are various examples of diagnostic related groups. Therefore, this section discusses two examples. One of them is DRG 638 (Diabetes with CC, complication or comorbidity (Pakdil et al.,2019). It is used for patients having diabetes and also having other comorbidities or complications which need the patient to be hospitalized some of the comorbidities include diabetic infections or foot ulcers, diabetic retinopathy, neuropathy, kidney problems and cardiovascular problems. Another example of DRG is DRG 193 – Simple Pneumonia and Pleurisy with MCC. This classification is used for patients with pneumonia and pleurisy and having a major comorbidity or complications. The comorbidities, include acute renal failure, shock, acute respiratory distress syndrome, septicemia and respiratory failure.

Insurance Reimbursement and Private Pay Patients

So far, it is evident that health insurance companies play a significant role in reimbursement as they pay the healthcare organizations after being billed for the healthcare services offered to their members. However, not every one chooses to have a health insurance cover. The implication is that such people may need to foot all the costs whenever they get healthcare services from the providers. As such, it is important to explore how insurance reimbursement affects private pay patients or those with no insurance covers (Mariotto et al.,2020). One of them comes in the form of direct costs effects. Usually the insurance reimburses usually involve negotiated costs which may mean that those with no cover may have to pay higher out of pocket costs. They have to be billed for full amounts hence higher payments. They are also impacted in terms of access to care. Healthcare organization often prefer patients with insurance covers, therefore, those without cover may experience longer wait times.

Apart from direct costs and access to care, healthcare reimbursement also impact private payers in other ways. The next aspect is financial struggles. The higher healthcare costs incurred by the private payers may lead to financial struggles due to depleted savings and the need to borrow funds to fill the gaps which may lead to long-term negative impacts (Mariotto et al.,2020). It also leads to healthcare disparities. Potential limited access to care and less comprehensive care can lead to disparities. There may also be a lack of cost transparency since the models can hide the actual costs of the services offered. Such an aspects denies them a chance to compare the prices for informed decision.

References

Chen, H. C., Cates, T., Taylor, M., & Cates, C. (2020). Improving the US hospital reimbursement: how patient satisfaction in HCAHPS reflects lower readmission. International Journal of Health Care Quality Assurance, 33(4/5), 333-344. https://doi.org/10.1108/IJHCQA-03-2019-0066

DeCherrie, L. V., Wardlow, L., Ornstein, K. A., Crowley, C., Lubetsky, S., Stuck, A. R., & Siu, A. L. (2021). Hospital at home services: an inventory of fee‐for‐service payments to inform Medicare reimbursement. Journal of the American Geriatrics Society, 69(7), 1982-1992. https://doi.org/10.1111/jgs.17140

Duncan, I., Ahmed, T., Dove, H., & Maxwell, T. L. (2019). Medicare cost at end of life. American Journal of Hospice and Palliative Medicine®, 36(8), 705-710. Doi: 10.1177/1049909119836204

Lin, J. C., Kavousi, Y., Sullivan, B., & Stevens, C. (2020). Analysis of outpatient telemedicine reimbursement in an integrated healthcare system. Annals of Vascular Surgery, 65, 100-106. https://doi.org/10.1016/j.avsg.2019.10.069

Mariotto, A. B., Enewold, L., Zhao, J., Zeruto, C. A., & Yabroff, K. R. (2020). Medical care costs associated with cancer survivorship in the United States. Cancer Epidemiology, Biomarkers & Prevention, 29(7), 1304-1312. https://doi.org/10.1158/1055-9965.EPI-19-1534

Maryati, W., Yuliani, N., Susanto, A., Wannay, A. O., & Justika, A. I. (2021). Reduced hospital revenue due to error code diagnosis in the implementation of INA-CBGs. Int. J. Public Health Sci.(IJPHS), 10, 354. DOI: 10.11591/ijphs.v10i2.20690

Mitchell, A., Baumrucker, E. P., Colello, K. J., Napili, A., Binder, C., & Braun, S. K. (2023). Medicaid: An Overview. Congressional Research Service (CRS) Reports and Issue Briefs, NA-NA.

Pakdil, F., Azadeh-Fard, N., & Esatoglu, A. E. (2019). Monitoring length of stay through control charts: a comparative study of diabetic patients. Hospital Practice, 47(4), 196-202. https://doi.org/10.1080/21548331.2019.1664883

Sen, S., & Deokar, A. V. (2021). Discovering healthcare provider behavior patterns through the lens of Medicare excess charge. BMC Health Services Research, 21, 1-18. Doi: 10.1186/s12913-020-05876-1

Tsai, Y., Zhou, F., & Lindley, M. C. (2019). Insurance reimbursements for routinely recommended adult vaccines in the private sector. American Journal of Preventive Medicine, 57(2), 180-190. https://doi.org/10.1016/j.amepre.2019.03.011

Xu, H., & Intrator, O. (2020). Medicaid long-term care policies and rates of nursing home successful discharge to community. Journal of the American Medical Directors Association, 21(2), 248-253. https://doi.org/10.1016/j.jamda.2019.01.153

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Important information for writing discussion questions and participation

Welcome to class

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Your initial discussion post should be a minimum of 200 words and response posts should be a minimum of 150 words. Be advised that I grade based on quality and not necessarily the number of words you post. A minimum of TWO references should be used for your initial post. For your response post, you do not need references as personal experiences would count as response posts. If you however cite anything from the literature for your response post, it is required that you cite your reference. You should include a minimum of THREE references for papers in this course. Please note that references should be no more than 5 years old except recommended as a resource for the class. Furthermore, for each discussion board question, you need ONE initial substantive response and TWO substantive responses to either your classmates or your instructor for a total of THREE responses. There are TWO discussion questions each week, hence, you need a total minimum of SIX discussion posts for each week. I usually post a discussion question each week. You could also respond to these as it would count towards your required SIX discussion posts for the week.

I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

Contact me if you have any questions.

Important information on Writing a Discussion Question

Your response needs to be a minimum of 150 words (not including your list of references)
There needs to be at least TWO references with ONE being a peer reviewed professional journal article.
Include in-text citations in your response
Do not include quotes—instead summarize and paraphrase the information
Follow APA-7th edition
Points will be deducted if the above is not followed

Participation –replies to your classmates or instructor

A minimum of 6 responses per week, on at least 3 days of the week.
Each response needs at least ONE reference with citations—best if it is a peer reviewed journal article
Each response needs to be at least 75 words in length (does not include your list of references)
Responses need to be substantive by bringing information to the discussion or further enhance the discussion. Responses of “I agree” or “great post” does not count for the word count.
Follow APA 7th edition
Points will be deducted if the above is not followed
Remember to use and follow APA-7th edition for all weekly assignments, discussion questions, and participation points.
Here are some helpful links
Student paper example
Citing Sources
The Writing Center is a great resource