Healthcare Reimbursement Options in the United States

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Healthcare Reimbursement Options in the United States

  • INTRODUCTION

    Reimbursement for services rendered by providers (physicians, physician assistants, and other providers) is generally made under one of two payment types: fee-for-service or episode of care reimbursement. Fee-for-service methodology is based on the premises that providers receive payment for each service rendered and is based on a set amount or price for each service. Included in this methodology are self-pay payments, retrospective payments, and managed care contracts.Under the episode of care methodology, providers receive one lump sum for all services provided related to a given condition or disease. Understanding each method of payment, its benefits and drawbacks, as well as its impact on cost control and resource utilization is important for those working in the health industry, as reimbursement impacts many decisions made about budgets, forecasts, strategy, and service line capacities.In this assessment, you will demonstrate your understanding of various reimbursement options within the context of a new patient consult. For this assessment, assume the role of a reimbursement specialist for a large primary care office. While you are aware that your providers are reimbursed in several different ways, the providers are uncertain as to what each reimbursement type means for the practice in terms of collections. They have requested that you outline the different reimbursement options to which the practice is subject for the providers in the group.

    DEMONSTRATION OF PROFICIENCY

    By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

    • Competency 1: Compare current trends and traditional methods of payment in the health care industry.
      • Explain payment options for uninsured patients, including how the patient would qualify for each option.
    • Competency 2: Assess health care reimbursement.
      • Describe drawbacks of the fee-for-service reimbursement model.
      • Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services.
      • Describe how pay-for-performance impacts reimbursement rates.
      • Describe how resource-based relative value scale or case-based payment encourages an overuse of services.
    • Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.
      • Adhere to the rules of grammar, usage, and mechanics.
      • Apply APA formatting to in-text citations and references.

    INSTRUCTIONS

    This assessment is based on the following scenario:

    • Patient scenario: Your office is seeing a new patient for the first time (new patient consults are $500).

    In your role as the reimbursement specialist for a large primary care office, outline the different reimbursement options to which the practice is subject for the providers in the group.Support your assertions with at least three academic sources. This may require you to do additional independent research. You may wish to consult the Health Care Administration Undergraduate Library Research Guide before you begin any additional research.This assessment has two parts.

    Part 1: Provider Reimbursement Options

    Present (at least) the four main reimbursement options that your provider in the scenario would likely have for a new patient consult. Describe the options and comment on potential drawbacks or additional considerations to take into account with each model. Also, consider the likelihood and challenges of recouping the entirety of the consult charges for the patient.Relevant scoring guide criteria:

    • Describe drawbacks of the fee-for-service reimbursement model.
      • “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.
    • Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services.
    • Describe how pay-for-performance impacts reimbursement rates.
    • Describe how resource-based relative value scale or case-based payment encourages an overuse of services.
    • Adhere to the rules of grammar, usage, and mechanics.
      • “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).
      • “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.
      • “Mechanics” refers to correct use of capitalization, punctuation, and spelling.
    • Apply APA formatting to in-text citations and references.
      • Be sure to include a separate References page.

    One potential way to organize this part would be as follows:

    • Fee-for-service.
      • What is it?
      • Consider health care spending and cost control; what are the drawbacks of this model?
    • Capitation.
      • What is it?
      • What are the potential drawbacks of this model for the physicians who are driven to provide comprehensive services to their patients?
    • Pay for performance.
      • What is it?
      • How does this model impact reimbursement rates?
    • Resource-based relative value scale or case-based payment.
      • What is it?
      • How can this model potentially encourage an overuse of services?
    Part 2: Payment Options for Uninsured Patients

    Identify and explain the potential payment options that would be available to the patient and your care provider if the patient in for the new patient consult had been uninsured. Also, be sure to discuss the ways that a patient could qualify for specific payment options, as well as the rationale for the associated appointment charge.Relevant scoring guide criteria:

    • Explain payment options for uninsured patients, including how the patient would qualify for each option.
      • “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.
    • Adhere to the rules of grammar, usage, and mechanics.
    • Apply APA formatting to in-text citations and references.

    One potential way to organize this part would be:

    • Medicaid.
      • How does the patient qualify?
    • Financing options.
      • What is this method?
    • Self-pay.
      • How would the patient be charged? A percentage of commercial contracts or a percentage of Medicare?
    • Charity care.
      • How would you screen a patient for charity care?
      • What process would you implement to qualify a patient for charity care?

    ADDITIONAL SUBMISSION REQUIREMENTS

    • Structure: Use the Reimbursement Options template [DOC] provided. Include a title page and references page when submitting your assessment.
    • Length: 3–5 pages, plus title and references pages.
    • References: Cite at least three current scholarly or professional resources.
      • Your textbook can be one of the three.
    • Format: Use APA style for references and citations only. Refer to:
    • Font: Times New Roman font, 12 point, double-spaced.
  • SCORING GUIDE

    Use the scoring guide to understand how your assessment will be evaluated.VIEW SCORING GUIDE

  • CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED
    Describe drawbacks of the fee-for-service reimbursement model. Does not identify any drawbacks of the fee-for-service reimbursement model. Attempts to describe drawbacks of the fee-for-service reimbursement model, but the description is inaccurate or incomplete. Describes drawbacks of the fee-for-service reimbursement model. Explains drawbacks of the fee-for-service reimbursement model, including the likelihood and challenges of recouping the entirety of the consult charges for the patient.
    Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services. Does not identify any drawbacks of the capitation reimbursement model as it relates to providing comprehensive services. Attempts to describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services, but the description is inaccurate or incomplete. Describes drawbacks of the capitation reimbursement model as it relates to providing comprehensive services. Explains drawbacks of the capitation reimbursement model as it relates to providing comprehensive services, including the likelihood and challenges of recouping the entirety of the consult charges for the patient.
    Describe how pay-for-performance impacts reimbursement rates. Does not identify how pay-for-performance impacts reimbursement rates. Attempts to describe how pay-for-performance impacts reimbursement rates, but the description is inaccurate or incomplete. Describes how pay-for-performance impacts reimbursement rates. Explains how pay-for-performance impacts reimbursement rates, including examples supported by citations to professional or scholarly literature.
    Describe how resource-based relative value scale or case-based payment encourages an overuse of services. Does not attempt to identify how resource-based relative value scale or case-based payment encourages an overuse of services. Attempts to describe how resource-based relative value scale or case-based payment encourages an overuse of services, but the description is inaccurate or incomplete. Describes how resource-based relative value scale or case-based payment encourages an overuse of services. Explains how resource-based relative value scale or case-based payment encourages an overuse of services and provides specific examples and sources.
    Explain payment options for uninsured patients, including how the patient would qualify for each option. Does not attempt to describe payment options for uninsured patients. Attempts to describe payment options for uninsured patients, but the description is inaccurate or incomplete. Explains payment options for uninsured patients, including how the patient would qualify for each option. Explains payment options for uninsured patients, including how the patient would qualify for each option, and provides examples and relevant resources to support the examples.
    Adhere to the rules of grammar, usage, and mechanics. Does not adhere to the rules of grammar, usage, and mechanics. Errors in grammar, usage, and mechanics inhibit readability and comprehension and detract from good scholarship. Adheres to the rules of grammar, usage, and mechanics. Exhibits strict and nearly flawless adherence to the rules of grammar, usage, and mechanics.
    Apply APA formatting to in-text citations and references. Does not apply APA formatting to in-text citations and references. Applies APA formatting to in-text citations and references incorrectly or inconsistently, detracting noticeably from good scholarship. Applies APA formatting to in-text citations and references. Exhibits strict and nearly flawless adherence to APA formatting of in-text citations and references.