Financial Resource Management and
Healthcare Reimbursement
Introduction:
The healthcare reimbursement system in the United States is complex. The health informatics professional needs an understanding of the basic principles of the third-party payer
system and the many options that are available to citizens through government-funded healthcare programs. Private and commercial insurance companies and Blue Cross and
Blue Shield plans offer a different menu of options to their clients. One issue is certain: All third-party payers are interested in decreasing healthcare costs while improving quality
and controlling access to unneeded services.
This task will allow you to examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete
this task, read the attached �A Lifetime of Healthcare Services,� which is a case scenario about a woman named Sophie. Then create a multimedia presentation, diagram, table,
or other illustration comparing the differences and similarities among the various insurance options and reimbursement systems that were used to pay for Sophie�s medical care
throughout her lifetime.
You are explaining these reimbursement systems from the perspective of a billing department manager training two new staff members. You believe that if you can explain these
systems with a real patient, it will be easier for your new staff to understand the various requirements of these reimbursement systems.
Task:
A. Compare Sophie�s health insurance options for each of the five phases of her life.
- Recommend the health insurance option that would provide the best coverage to meet Sophie�s needs during each phase.
a. List the elements of each plan you recommended.
b. Discuss the reimbursement requirements of each plan you recommended.
c. Discuss restrictions to each plan you recommended.
B. When you use sources, include all in-text citations and references in APA format.
Note: When using sources to support ideas and elements in a paper or project, the submission MUST include APA formatted in-text citations with a corresponding reference list
for any direct quotes or paraphrasing. It is not necessary to list sources that were consulted if they have not been quoted or paraphrased in the text of the paper or project.
Note: No more than a combined total of 30% of a submission can be directly quoted or closely paraphrased from sources, even if cited correctly.
Phase 1
In the initial phase, Sophie was jobless, had young children, and
her husband was working. Sophie had the following health
insurance options during the first phase:
- Family health insurance coverage which provides coverage
for herself, her husband and their children.
2.
Individual health insurance coverage which only covers
herself.
Phase 1 recommended plan
For phase 1, the recommended health insurance option
which would offer the best coverage to meet Sophie’s
need is family health insurance.
The elements of this plan include: the insured must
have children who are below the age of 18 years; and
one needs to pay a premium (Rimmer, 2009).
Reimbursements requirements and restrictions
For Sophie to be reimbursed, the requirement is that she must
provide proof of payment and proof that the coverage was in force
during the time represented by the payment (Ubel, 2013).
An employer could set up a health reimbursement arrangement
(HRA) for her/his workers and employers are allowed to reimburse
their employees for insurance premiums.
Reimbursements might be tax-free if her husband pays qualified
medical expenses.
Phase 2
Sophie had the following health insurance options
during the second phase:
1.
Managed Care Health plan; and
2.
Medicaid.
Phase 2 Recommended plan
The recommended health insurance option is Managed Care
plan health insurance. This would definitely provide the best
coverage to meet Sophie’s needs.
The elements of this option comprise the following: emergency
care, prescription drug coverage, doctor office visits and has
good drug benefits (Green & Rowell, 2010; Mollica, 2009).
Reimbursement requirements and restrictions
With this option, she has to provide proof of payment and proof that the
coverage was in force during the time represented by the payment.
This option can be done on Health Arrangement Reimbursement (HRA)
plan, a tax-advantaged benefit that should be financed only by the employer
and not salary deductions.
The HRA plan might offer benefits only for substantiated medical
expenditures. This simply means that under HRA, every request for
reimbursement has to be substantiated (Gidwaney, 2010).
Phase 3
Sophie had the following health insurance options
during the third phase:
1.
Medicare Part A – Medicare Individual Plan; and
2.
Retirees Health Cover which is essentially a
private health insurance.
Phase 3 recommended option
The preferred health insurance option is Medicare Individual Plan. This
basically applies to someone who is 65 years of age or older. Its benefits
include no monthly premium, offers higher hospital visits as well as
prescription drugs. It also provides good drug coverage plan (American
Cancer Society, 2013).
As such, this health insurance plan will meet the needs of Sophie. With the
new healthcare legislation, the benefits of Medicare have expanded things
such as annual wellness visits and free preventive benefits.
Reimbursement requirements and restrictions
It is only under extremely extraordinary situations will Medicare reimburse a
Medicare patient in a direct way for expenditures associated to the medical care of
the patient (Joyner, 2013).
In essence, the Medical claims of the patient would be sent straight from the
patient’s Medicare providers to Medicare. After that, payments would be sent
straight from Medicare to the patients Medicare providers in accordance to the rates
of Medicare reimbursements (Medx, 2014).
It is noteworthy that Medicare reimbursements apply only to charges that relate
directly to medical care and not to Medicare premiums or Medicare deductions.
Phase 4
Being at an assisted living facility, Sophie had the
following health insurance options during the fourth
phase:
1.
Medicare Part A hospice which comprises
hospices covered by Medicare; and
2.
Medicare Advantage plan (Mollica, 2009)
Phase 4 Recommended option
The recommended health insurance option is Medicare that supports
hospice services.
The elements of this insurance option include the following: no monthly
premium, pays for hospice care, assisted living, home-health care, care in
Medicare-certified nursing facilities and hospital care (American Cancer
Society, 2013).
This option suits Sophie’s needs primarily because she has a terminal illness
and she requires to live in assisted living facility and needs hospice care.
Reimbursement requirements and restrictions
Medical claims of the patient would be sent from the patient’s
Medicare providers directly to Medicare. Payments would then be
sent straight from Medicare to the patient’s Medicare providers as
per the rates of Medicare reimbursements (Medx, 2014).
In essence, Medicare reimbursements are applicable only to charges
that relate directly to medical care and not to Medicare deductions or
premiums.
Phase 5
Skilled Nursing Facilities are facilities offering twenty-four hour medical,
supervision and rehabilitative services for patients who require a high level
of care (Centers for Medicare & Medicaid Services, 2013).. Being in a skilled
nursing facility, Sophie had the following health insurance options during
the fifth phase:
1.
Medicare that covers skilled nursing care – Medicare-covered skilled
care; and
2.
Medicaid.
Phase 5 recommended option
The recommended option is Medicaid.
The elements for this plan include the following: it only pays
for nursing care only when is provided within a
Medicaid-certified facility. Moreover, it only pays for persons
who have limited resources and income. This satisfies the
needs of Sophie because her financial resources were depleted
after only 1 year at the skilled nursing facility.
Reimbursement requirements and restrictions
Medical providers can only bill Medicaid with services provided that
are deemed to be medically essential. In addition, they have to
present proper diagnosis as well as documentation of the service
which they offered along with their billing statement. Moreover, in
order to be reimbursed, the medical provider has to submit a claim
form stating the type of procedure/service or treatment that was
provided to the patient (Layman & Casto, 2006).
Cont’d
It is noteworthy that every state has its own rate of
reimbursement for medical services offered under
Medicaid (Ubel, 2013).
References
American Cancer Society. (2013). Health Insurance and Financial Assistance for the Cancer
Patient.