- MBA FPX 5006 Assessment 1 Strategic Process and Analysis.
Health Care Finance Overview
Ladies and gentlemen, distinguished guests, and fellow workers, I am glad to welcome you to the talk on the health care finances. Although financial issues may not be directly related to the provision of patient care services, managing financial matters remains a crucial competence area for all healthcare personnel, ranging from doctors to healthcare facility directors. Thus, purchasing health care has not been constant; it has evolved, for example, after the enactment of the ACA in 2010.
These changes have impacted healthcare organizations’ general financial structure, influencing quality, cost, and patient-centered care (EA, 2010; Shan et al., 2021). Heath care finance is a branch of knowledge that incorporates several aspects in health care including money making, reimbursement, financial planning and reporting, and management and administration of funds in health care organizations. Various health care executives and managers must know these concepts to continue to be profitable while delivering quality services to patients.
Purpose of Health Care Reimbursement Programs
The processes of Public and Private insurance claims, including Medicaid, Medicare, and Managed care, are still relevant to the US healthcare facilities’ payment systems and their role in supporting different patient populations (Farkas et al., 2020). These programs are still relevant, and they have certain objectives that assist various clients while at the same time assisting health centers in achieving their overall financial management strategies. For instance, Medicaid is a federal and state program that aims at providing medical care and support to low-income individuals, pregnant women, children, the elderly, and the disabled individuals (Kongstvedt, 2020).
Specifically, its objective was to address who was supposed to receive the proper medical care for specific categories of people who otherwise would not be able to obtain medical care. The rules concerning eligibility and enrollment in Medicaid also vary from one state to another. Still, they usually depend on the person’s gross income and other factors set by the Medicaid program of the respective state.
In turn, participating in the Medicaid program will provide healthcare organizations with new patients, including patients from low-income households, and a significant source of income that will help cover costs of care that are not reimbursable by insurance and stabilize the organizations’ revenues. Medicaid funding assists in guaranteeing that the population in need of this service receives essential medical care and also contributes to enhancing other costly health services within society.
MBA FPX 5006 Assessment 1 Strategic Process and Analysis
Medicare is a federal health insurance program that covers selected beneficiaries 65 years and older, those with disabilities, and those with ESRD (Kongstvedt, 2020). Medicare is another name used for the program. It has specific strategies to provide health care services, including hospitals, skilled nursing homes, hospice facilities, and prevention. Medicare is mainly for people sixty-five years of age or above or individuals with a disability.
To qualify for the program, one must have contributed dues to the program via the payroll taxes or through the previous work record of a spouse (Kongstvedt, 2020). As for the payment, health care organizations have noticed that Medicare payment is beneficial because it establishes the cost per discharge, case mix, diagnosis-related groups, or fee plan. Enrolling in Medicare enables an organization to continue offering quality services to the elderly and individuals with chronic diseases. This supports providing care services in a regular and full capacity for patient’ care.
Reimbursement Process
This paper focuses on health care reimbursement as one of the key elements of healthcare institutions’ financial management. It ensures that patients are fairly compensated for their health care (Kongstvedt, 2020; Shi & Singh, 2020). This type of process consists of several active stages, including several socio-structural measures that need to be implemented by a certain date and that require companies to adhere to specific legal procedures to make refunds. It begins with the caregiving process, where caregivers record all aspects of a patient, including the patient’s diseases, therapies, medications, and drugs to take, among other clinical details (Shi & Singh, 2020). In this process, it is crucial to have all accurate paperwork, because it is a starting point for all the compensation procedures.
MBA FPX 5006 Assessment 1 Health Care Finance Overview
The following procedure is to code and bill the services given and document them so the patient can be reimbursed. The diagnoses made are coded under ICD codes, while the treatments are coded under CPT codes. The healthcare givers or coding specialists provide these codes to capture the required services (Kongstvedt, 2020; Shi & Singh, 2020). Another significant function of these codes is to indicate the correct quantity and kind of remuneration for the services they define. This means they must obey payers’ coding conventions and guidelines to ensure payment is not delayed or rejected.
Lastly, the healthcare organization compiles the paperwork required to complete a claim form, following coding. Afterwards, this form is submitted to the correct payer, which can be Medicare or Medicaid, the insurance companies, or managed care organizations(Kongstvedt, 2020). These forms can also be completed and submitted online if one prefers, or the forms can be submitted via hard copy if that is more convenient. Adjudication is the first stage of the claim examination by the payers to check if the claim complies with the contract and policy rules. This entails, for instance, finding out if it is accurate and if it encompasses all the required aspects. In this step, they ensure that the patient’s data follows the medical needs and that the patient is not being billed for services beyond the necessary charges.
Challenges that Health Care Organizations Face in Terms of Reimbursement
Another challenging issue that is evident in managed care organizations is the issue of reimbursement for the health care services provided. This problem impacts the financial aspect of the organizations and the quality of health care delivery in general. These are the problems with this payment method: A significant issue is the time required to recover the costs of the service received.
Payment for the allowed claims can take several weeks to several months to be processed and issued to the concerned provider. This is determined by the payer’s processing time, the specific claim type, and the requirements for documentation and coding of the claim (Fischer and colleagues, 2021; Kozak and colleagues, 2019). For instance, the largest payer in the healthcare facility, Medicare, processes claims submitted online within 14 to 30 days. The duration may take longer if the claims were sent through paper or require more examinations (Centers for Medicare & Medicaid Services, 2020). Such delays can affect the cash flow of healthcare organizations, thus affecting their operating capital. However, small groups and healthcare facilities with limited budgets struggle to cover daily expenses and invest in improving patient care.
It also has problems concerning the manner and time of receipt of its payment and problems with Medicare and Medicaid, insurance companies, and MCOs. Basically, there are many methods to how organizations pay for services, the amount they pay, and which services they are ready to pay for. This is the case with virtually all services that could be provided for a fee. For example, Medicaid has different programs in different states with different rules concerning eligibility, the type of services offered, and the contribution one has to make. These rules can influence factors such as cost control, administrative functions, and the time it takes to repay the money.
Data and Quality Metrics
Therefore, healthcare organizations must provide proof and details of the services they offer to be entitled to the right payment. Such values are necessary to discuss the quality, effectiveness, and outcomes of the services and to fulfill all the conditions set by payers and other regulators.
Accurate and proper documentation and filing of patients’ records also ensure that you get paid. Evaluations, methods, and medications must also be documented and coded properly in sets, such as ICD-10 and CPT. This not only proves that the stated services are clinically required but also assists in determining remuneration through the use of DRGs or fee Schedules (Kongstvedt, 2020; Shi & Singh, 2020).
First, payers must address the quality of care success measures to stimulate the population’s interest in value-based payment models. These measures can sometimes indicate the patient’s perception of symptoms or other health concerns, safety, happiness, and quality, which may include compliance with the set standards. For instance, hospitals may exhibit various result indicators, including the frequency of readmissions, the cases of infections, the patients’ satisfaction, and the compliance with the set practices and procedures. These are general methods of assessing the effectiveness of the healthcare services (Fischer et al., 2021).
Tracking numbers related to customer satisfaction and experience is critical to payment, particularly for the programs that analyze value. They must also monitor and document patients’ satisfaction levels with aspects such as their ability to engage with healthcare personnel, staff manners, and the general environment of the hospital. These measures indicate that care is patient-centered and used in payment to providers, depending on the patient’s satisfaction.
Conclusion
Reflecting on the case, it is possible to state that money management is vital not only for healthcare organizations but for anyone working in the sphere. The rules and policies, the roles of different payers, and the types of people who get health care are not constant at all; that is why health care payment is constantly changing. It is a branch of health management encompassing elements such as the budget, financial reports, and strategy to ensure that the facility continually attends to patients.
Due to concerns with reimbursement, people who work in the healthcare business face the following problems: issues with claims processing, inconsistency in the rules that apply to payers, and the unequal dispersal of funds. Such things can only be achieved when the RCM policies are strong, proper documentation is in place, and the organization is aligned with the performance standards.
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