Components, Restrictions, and Reimbursement Process in Insurance Plans
Please look at the rubric too along with the instructions.
Task 2: Examining Healthcare Reimbursement Systems
Introduction:
The healthcare reimbursement systems in the United States are complex. A health information management 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 offer a different menu of options to their clients. All third-party payers are interested in decreasing healthcare costs while improving quality and controlling access to unneeded services.
In this task, you will examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete this task, you will discuss each type of healthcare insurance plan listed, as well as the plan components, reimbursement provisions, restrictions, and the impact of government regulations.
Requirements:
Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. Use the Turnitin Originality Report available in Taskstream as a guide for this measure of originality.
You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.
A. Discuss the components of each of the following insurance plans:
- Fee for service (indemnity) plans
- Managed care plans
- Government-sponsored health plans (i.e., Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).
- High-deductible health plans/healthcare savings accounts
B. Discuss the restrictions of each of the following insurance plans:
Fee for service (indemnity) plans
- Managed care plans
- Government-sponsored health plans (i.e., Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).
- High-deductible health plans/healthcare savings accounts
C. Discuss the inpatient reimbursement process for each of the following insurance plans:
- Fee for service (indemnity) plans
- Managed care plans
- Government-sponsored health plans (i.e., Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).
- High-deductible health plans/healthcare savings accounts
D. Discuss the outpatient reimbursement process of each of the following insurance plans:
- Fee for service (indemnity) plans
- Managed care plans
- Government-sponsored health plans (i.e., Medicare, Medicaid, State Children's Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).
- High-deductible health plans/healthcare savings accounts
E. Analyze the impact the Medicare and Medicaid Patient and Program Protection Act of 1987 had on Medicare and Medicaid.
F. Discuss how third-party payment calculations impact healthcare reimbursement in healthcare organizations.
G. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.
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CNP Task 2 (1116)
Examining Healthcare Reimbursement Systems
Name
Institution
Date
Components of the Insurance Plans
- Fee for service (indemnity) plans
• Managed care plans The managed care plans (HMOs, PPOs and POS) have elements like the network, the medical homes that play the primary gatekeeper role, prior authorization or pre-certification where there is oversight of elective procedures or specialty visits, the benefits package, formulary and the utilization management.
• Government-sponsored health plans Medicare help pay for the hospitals, skilled nursing facility home health and hospice care for the disabled and aged where there is no premium and there are supplemental medical insurance elements to help pay for the aged and disabled who enrolled voluntarily. The government programs subsidize medical costs for those covered and Medicaid is applicable for the low-income individuals who are medically needy and includes special groups. All eligible patients must meet the requirements for the programs funded by state and federal funds. High-deductible health plans/healthcare savings accounts The HDHP is paired with the HAS and the plans have high annual deductibles compared to the other health insurance plans, but they also set a limit for the deductibles and the out-of pocket expenses. The plans may provide preventive care without the deductibles, while the plans also identify qualified medical expenses that are deductible and are not taxed.
B. Restrictions of the Insurance Plans
Fee for service (indemnity) plans There are no restrictions on the choice of members under this option while the physicians are paid what are normally the usual and customary charges (Berger, 2008). Typically, covers a broad range of tests and procedures.
Managed care plans For the patients enrolled in the managed care plans there are restrictions on the network of hospitals, physicians and other providers, this depends on the type of managed care including the health maintenance organizations (HMOs), preferred provider organizations (PPOs). The restrictions on choices in managed care lower costs for those using the managed products. at other times there are formulary restrictions that influence the quantity limits, preferred drug lists and cost sharing (Happe et al., 2014)
Government-sponsored health plans Medicare covers people aged 65 years and older and those who are permanently disabled, while Medicare is utilized by low-income people who cannot afford the medical care services. TRICARE covers the medial services for the active duty members of their members, their dependents, their spouses, children, the retired military personnel their spouses and children, depends as well as those of the deceased active-duty personnel, and all other people are excluded (Berger, 2008). The State Children’s Health Insurance Program (SCHIP) expands Medicaid eligibility and includes the uninsured children. The Indian Health Service (HIS) restricts billing services to the self-insured plans and covers only the American Indian and Alaska Natives.
•High-deductible health plans/healthcare savings accounts
The HDHP and HSA minimum and maximum deductible differ for both the two insurance coverage plans with the Maximum Annual HSA Contribution being $ 3,400 for individual coverage and $ 6,750 for family coverage, while Minimum HDHP Deductible is $1,3000 for individuals and $ 2,6000 for families (Segal Consulting, 2016). Similarly, the Maximum HDHP Out-of-Pocket Expense is $ 6,550 in individual coverage and $ 13,000 for family coverage (Segal Consulting, 2016).
C. Inpatient reimbursement process
• Fee for service (indemnity) plans The services provided for inpatient services are included in the coverage and the payment system reimburses individual charges for the hospital care irrespective of the use of services and length of stay in hospital. The states select the different payment methods for the inpatient reimbursement process depending on whether they chose the diagnosis-related groups (DTGs) or other approaches that reimburse the reported costs charged to health care organizations.
• Managed care plans There are diverse methods to reimburse the providers and the reimbursement tends to be less than what the providers received in the past payment. the most common approach is the defined dollar amount, and if this not the preferred method, the percentage of charges is chosen, followed by the charges, the DRGs. at other times leasing and capitation are chosen and the last phase is penalties and w...