Write a 45-minute lecture plan for an introductory health care finance class
Write a 45-minute lecture plan for an introductory health care finance class
The success of a particular healthcare system depends on proper healthcare planning. Among the pillars of healthcare, planning is healthcare finance. Healthcare financing, which usually requires a proper address, includes payment incentives, allocation and utilization of services, distribution of financial risk, and mobilization of funds (Cai et al., 2020). Various revenue sources for healthcare financing exist in the USA. The healthcare economy remains competitive in the USA, implying that individuals and companies have various options open to finance healthcare. Alongside the public healthcare financing programs operated by governments, there are also private options.
The purpose of this lecture is to explore Medicaid, Medicare, and Managed care. The purpose of each program will be explained, and analyses of the reimbursement for the health care organizations analyzed. In addition, steps required to receive reimbursement and complications of each step, the information required from the organizations, and the length of time required to receive reimbursement will also be discussed. Finally, the lecture will seek to explain the benefits of each program for both patients and health care organizations.
Purpose of the Programs
Medicaid was formulated in 1965 as a public insurance program to offer health coverage to various people such as individuals with disabilities, senior citizens, pregnant women, children, and adults from low-income families. This insurance program is jointly funded by the State governments and Federal governments (Anderson-Cook et al. 2019). While the Federal government creates the program’s guidelines, the program varies from one State to another. On the other hand, Medicare, usually confused with Medicaid, has a different specific purpose. Established the same year as Medicaid, this plan was originally meant for individuals of at least sixty-five years. However, it was later expanded to include coverage for specific individuals with kidney failure or end-stage renal disease and for individuals with some types of disabilities.
Managed care refers to health insurance that contracts with particular healthcare providers with the focus of reducing the costs of services offered to their members (Anderson-Cook et al., 2019). Under the managed care, a legal agreement is signed between the provider and the health insurance company that the provider will offer the agreed chosen services at a lowered cost. The insurance companies also agree to limit the member’s options to the providers.
The Process of Reimbursement
Understanding the reimbursement methods used in the various systems can be complex, which is, understanding where the money
originates and how individuals benefit. The reimbursement process for Medicaid depends on the model employed by the State. Medicaid operates under two models, the Managed Care Model and the Free-For-Service model. In the case where the State uses the Manage Care model, the State pays capitated rates, per-member or per-month payment irrespective of the received services (Enders et al., 2021). On the other hand, in the Free-For-Service model, the Medical Assistance program run by the State pays the providers a standard rate for a specific medical service.
A different process is followed for Medicare reimbursements. While it is not always that reimbursement claims be filled in the case of Medicare, sometimes it is necessary to claim for reimbursement of out-of-pocket medical spending. Medicare reimbursement is divided into various parts. The Part A reimbursements cover tests, medications, equipment, doctors, and services obtained in the hospital as an inpatient (Enders et al., 2021). The doctors usually bill Medicare, covering most of the services groups under part A. Part B reimbursements entail preventive services, outpatient care, and doctor visits. In addition, part D reimbursements deal with drug prescription coverage. The drug companies set their own rile concerning the kind of medications to be covered and ones that are not. Part C is private insurance and also gives extra coverage on prescription drugs, vision, and dental, among others.
Managed care organizations are divided into the Exclusive Provider Organization, Point of Service Organizations, Preferred Provider Organizations, and Health Maintenance Organizations. Managed care reimbursements are done using two models, fee-for-service and value-based care reimbursement models (Green, 2018). In the fee-for-service model, the organizations reimburse the providers for every service they offer to their members. In most cases, the fee-for-service models are integrated with other methods to ensure that costs are controlled. The value-based care reimbursement model hinges on capitation. In the capitation arrangement, the providers get reimbursed specific amounts each month for the enrolled members who get services from them.
Steps Taken for Reimbursements and the Complications of Each Step
The reimbursement process or the steps taken in order to receive reimbursement for services offered also differ from one revenue source to another. In the Medicaid plan, claiming a reimbursement, a staff has to sign and submit a confidential form and have the appellant also since for 113. Signing and submitting a confidentiality form is relatively easy as it only needs signing. The provider also signs the same form. Form 112, containing the requested reimbursement costs together with the claim forms approved by Medicaid, are then submitted for reimbursement (Green, 2018). Getting the forms approved by Medicaid is one of the complicated steps as various documentation has to be verified for authenticity and accuracy.
The steps taken for Medicare reimbursements are different from the other model. In the Medicare model, once there is an outstanding claim, a call is made to the service provider to request them to make a claim. The step of calling the provider may be easy, but complications arise when the provider is not ready to make claims, and the individual has to make a claim. In the event that they cannot make a claim, the individual can also make a claim by downloading the form and filling it (Green, 2018). The form patient request for medical payment form is obtained from the Medicare.gov website.
While the form could be available at the website for download, it may not be a straightforward exercise as an individual may need further help downloading the right form and filling it. The form is filled in details, making it clear why the claim form is being filled and offering the itemized bill. Any supporting information for the reimbursement is also included. The filled form is then mailed to the Medicare contractor (Green et al., 2018). In case there is a need to designate another individual to file the claim or talk to Medicare, then the authorization to disclose personal health information form should be filled.
Under the managed care, various steps are taken to receive payment for the services offered. A provider or a physician fills a clean claim form to trigger the process of reimbursement. Filing a clean claim form is not a complicated process as the physician only needs to obtain the right form, fill it and send it. When a managed care organization receives a clean claim, then various procedures have to be undertaken within thirty days (Green et al., 2018). The organization pays the total amount or part of the claim following the contracts signed or denies part of the entire claim. In the case of denial, the organization has to let the provider know why the payment for the claim has been denied. The step of processing payments for the claims is complicated since it requires various steps of verifications, hence leading to higher chances of delayed payments.
The Information Required from the Organization
For healthcare provider organizations and individual health providers to get reimbursed for the services offered, they have to provide various information for the processing and eventual reimbursement. For Medicaid, various information is needed, including the name of the person who used the service. The name, address, and the contact details of the facility or the physician that offered the service, the date when the service was provided, diagnosis and procedure codes, the billed charges amounts, and payment verification (Green et al., 2018). The other information needed includes the proof of payment by private insurance, if any, in the case of durable medical equipment, the proof of medical necessity from the prescription, and the physician is needed. In the case of dental service, procedure and diagnosis codes for every tooth are needed. In addition, for a pharmacy service, prescription data, retain cash price, quantity dispensed, and national drug code is needed.
In the Medicare plan, like the Medicaid, various information is needed to process claims and reimburse for the services offered. Some of the information needed include an itemized bill majorly. The itemized bill usually carries information such as the doctor or the health provider’s name and address, the charge for every medical supply or service offered, a detailed description of each medical supply or service, the date of service (Green et al., 2018). Apart from the itemized bill, the other information needed is details regarding the diagnosis
Length of Time Required to Receive Reimbursement
The process followed to receive reimbursement for services offered by various healthcare provider organizations or clinicians is different for every insurance plan. The implication is that the time required to receive reimbursement for services offered is also different. For Medicaid, the time for reimbursement greatly varies depending on how the claim was made (Brown, 2019). In the case the billing is properly made, it can take up to two weeks to get the reimbursement. That means the claim forms have to be submitted by the deadline; otherwise, reimbursements wait up to the next cycle. Approvals usually wait until the proper documentation and information are needed.
Reimbursement by Medicare also depends on the claim parts. Upon submission of claims for parts A and B to Medicare, it takes roughly one month to process and pay the claim. This period can be longer if there are issues to be addressed. While clean claims submitted electronically takes two weeks to process and settle, the paper versions take up to one month to complete (Brown, 2019). For managed care, the duration can also be up to thirty days but is also dependent on the presence or absence of issues.
Benefits for Patients and Organizations
The programs offer benefits for both the patients and organizations. Medicaid increases access to care and the use of healthcare hence improving individuals’ health. People can use preventive care options, which help in ensuring that they have better health outcomes. Medicaid also allows organizations to offer improved patient care and service, hence improving the image and avoiding loss of revenue due to medical mistakes (Brown, 2019). Medicare also has various benefits, such as relatively lower costs due to the existing competition. As such, patients also receive better care services, hence improving their life quality. Medicare has also enabled healthcare providers and organizations to offer quality care and generate enough revenue to run the centers.
Conclusion
In conclusion, this lecture has covered healthcare financing with a major focus on Medicaid, Medicare, and managed care. The systems have been explored under various aspects, such as a detailed description of each, the reimbursement processes used by each, and the steps followed for reimbursement of services to be done. In addition, the benefits of each program for patients and healthcare organizations have been explored.
References
Anderson-Cook, A., Maeda, J., & Nelson, L. (2019). Prices for and spending on specialty drugs in Medicare Part D and Medicaid: an in-depth analysis. Washington, DC: Congressional Budget Office.
Brown, E. R. (2019). Medicare and Medicaid: The Process, Value, and Limits of Health Care Reforms. In Readings in the political economy of aging (pp. 117-143). Routledge.
Cai, C., Runte, J., Ostrer, I., Berry, K., Ponce, N., Rodriguez, M., … & Kahn, J. G. (2020). Projected costs of single-payer healthcare financing in the United States: a systematic review of economic analyses. PLoS medicine, 17(1), e1003013. https://doi.org/10.1371/journal.pmed.1003013.
Enders, D., Schink, T., & Stürmer, T. (2021). Medicaid and Medicare. In Databases for Pharmacoepidemiological Research (pp. 231-242). Springer, Cham. DOI: 10.1007/978-3-030-51455-6_19.
Green, M. (2018). Understanding health insurance: A guide to billing and reimbursement. Cengage Learning.