BHA FPX 4009 Assessment 2 Reimbursement Options

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Capella University

BHA-FPX4009 Health Care Reimbursement Systems

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Introduction

This article presents a comprehensive examination of diverse reimbursement alternatives in healthcare while exploring various payment methodologies. Furthermore, it delves into the drawbacks and repercussions on reimbursement rates affiliated with fee-for-service, capitation, pay-for-performance, and resource-based relative value scale (RBRVS) models. Additionally, this study assesses alternative payment avenues for uninsured patients, encompassing Medicaid, self-pay, and financing options.

Part I – Provider Reimbursement Options

Fee-For-Service

Fee-for-service (FFS) denotes a reimbursement paradigm where healthcare providers receive compensation for each service rendered, based on charges or a pre-set fee schedule (Rosenthal, 2007). This schedule delineates the fees sanctioned by third-party payers for healthcare provisions (Casto, 2019A). Critics contend that FFS lacks incentives for cost containment and might engender service overutilization (Casto, 2019A). Providers could augment revenue by extending more services per patient, yet reimbursement hinges on the complexity of care dispensed (Fearnley, 2016). Although FFS is widely practiced globally, nations adopt variations tailored to their healthcare frameworks and funding sources (Ikegami, 2015). For instance, Canada embraces a hybrid model amalgamating social insurance and national health services (Casto, 2019A).

Capitation

Capitation entails fixed payments per individual per month (PMPM) to healthcare providers, irrespective of services availed (Casto, 2019A). Under this model, providers might circumvent high-cost patients to optimize profits (Casto, 2019A). However, predicting reimbursement becomes intricate due to the fixed nature of payments (Fearnley, 2016).

Pay-for-Performance

Pay-for-performance stimulates quality care delivery through financial incentives (McKethan & Jha, 2014). It accentuates patient outcomes, processes, and experiences (Mongan et al., 2008). Initiatives such as the Hospital-Acquired Condition Reduction Program endeavor to enhance care quality by penalizing specific conditions (Pay for Performance Reimbursement, 2019). This model aligns with endeavors to augment quality while managing costs (Rosenthal, 2007).

Resource-Based Relative Value Scale

RBRVS remunerates healthcare services predicated on requisite resources and appropriate prices for service units (Casto, 2019B). Enacted in 1992, RBRVS aims to standardize physician reimbursements (DeVries, 2019). Reimbursement computation involves a formula integrating relative value units and practice expenses (DeVries, 2019).

Part 2 – Payment Options for Uninsured Patients

Identifying and Explaining Payment Options for Uninsured

Medicaid furnishes coverage for individuals and families with low income (Casto, 2019A). Despite endeavors to broaden insurance coverage, options like Medicaid retain significance for the uninsured (Rosenthal et al., 2016). Additionally, financing alternatives and self-pay discounts are viable. Financing entities may proffer payment plans contingent on income, while self-pay patients can negotiate reduced rates (Lamberti, 2021).

Conclusion

Healthcare reimbursement models wield substantial influence over patient care and organizational finances (Casto, 2019A). Proficiency in comprehending these models is imperative for optimizing service provision and reimbursement. While traditional models persist, there exists a shift towards performance-based frameworks to enrich quality and curtail costs (Rosenthal, 2007).

References

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Casto, A. B. (2019A). Chapter 1, “Healthcare Reimbursement Methodologies.” Principles of healthcare reimbursement (6th ed.). AHIMA Press. Pages 1-19.

Casto, A. B. (2019B). Chapter 7, “Ambulatory and Other Medicare-Medicaid Reimbursement Systems.” Principles of healthcare reimbursement (6th ed.) AHIMA Press. Pages 139-194.

DeVries, T. (2019). RBRVS Overview. MD Management Group. Retrieved from https://mdmanagementgroup.com/rbrvs-overview/

Fearnley, A. (2016, April 7). Capitation vs. Fee-for Service Healthcare Payment Models. PrognoCIS. Retrieved from https://prognocis.com/capitation-vs-fee-for-servicehealthcare-payment-models/

Ikegami, N. (2015). Fee-for-service payment- an evil practice that must be stamped out? Int J Health Policy Manag. 4(2), 57-59. Retrieved from https://pubmed.ncbi.nlm.nih.gov/25674568/

Lamberti, P. (2021). What to do When You Get Medical Bills You Can’t Afford. Money Under 30. Retrieved from https://www.moneyunder30.com/paying-medical-bills-you-cantafford

Mckethan, A., & Jha, A. K. (2014). Designing smarter pay-for-performance programs. JAMA, 312(24), 2617-2618.

BHA FPX 4009 Assessment 2 Reimbursement Options

Mongan, J. J., Ferris, T. G., & Lee, T. H. (2008). Options for slowing the growth of health care costs. The New England Journal of Medicine, 358(14), 1509-1514.

Pay for Performance Reimbursement. (2019, July 20). The Fox Group. Retrieved from https://www.foxgrp.com/assessment-benchmarks/pay-for-performance-reimbursement/

Rosenthal, M. B. (2007). Pay for performance and beyond. Expert of Pharmacoeconomics & Outcomes Research, 7(4), 351-355.

BHA FPX 4009 Assessment 2 Reimbursement Options

Rosenthal, M. B., Landrum, M. B., Robbins, J. A., & Schneider, E. C. (2016). Pay for performance in Medicaid: Evidence from three natural experiments. Health Services Research, 51(4), 1444-1466.