Examining Health Reimbursement Systems

Examining Health Reimbursement Systems
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Examining Health Reimbursement Systems
Healthcare reimbursement is an essential process in the medical field. It involves payments that the health providers receive for the services they deliver. Payment must occur after the service delivery to allow the healthcare providers to calculate the average cost. Third-party reimbursement is also significant since it allows the patients to pay fewer costs leading to high-quality care. They also reduce negotiation, thus providing better services at an affordable cost, such as effective insurance plans. Many insurance plans guide effective healthcare service provision leading to efficiency in health care. The paper examines different insurance plans, including high-deductible health plans, government-sponsored, managed care, and fee-for-service plans.
A. Components of the Insurance Plans
Fee-for-Service Plans
Fee-for-service is a major type of insurance plan traditionally used. It allows the patients to pick hospitals and physicians of their choice anywhere. It is a bit expensive but composed of limited restrictions. The plan allows the patient to pay a particular amount of money, leaving the remainder to the insurance provider (Britton, 2015). It is composed of a deductible monthly premium that the insurance providers consider. Therefore, it relieves the patient from paying for the whole service.
Managed-Care Plans
Managed-care plans are composed of point of service, exclusive provider, health maintenance organization, and preferred provider, among others. However, managed care plans are unique from each other in different ways. Others do not need primary physicians, while others do. It is also composed of varying cost-sharing depending on the insurance plans. Among the provided list, the health maintenance organization is the cheapest due to low monthly premiums regardless of the emergencies (Shrank et al., 2018). Therefore, managed care plans play a significant role in establishing equitable healthcare.
Government-Sponsored Health Plans
Government-sponsored health plans are commonly used in the medical field. The most common elements include Medicare, Medicaid, and SCHIP. They are government-funded insurance plans that benefit different individuals. For instance, Medicare is provided to 65-year-old individuals and above, especially the disabled (Britton, 2015). It is divided into part A, B, and C, which plays unique roles and has varying monthly premium. Medicaid advocates for individuals with low income and varies depending on the state. SCHIP also varies depending on the state and covers families and children with financial problems acquiring medical care. Tricare covers retired and active military officers. Therefore, government-sponsored health plans positively benefit the patients by reducing their costs.
High-deductible health plans
High-deductible health plans are critical since it accumulates a low monthly premium. HDHP is more effective than the traditional plans since it caters to individuals and families separately. The deductible for individuals ranges between $6650 and $1350; the family's deductible is between $13300 and $2700 (Larson et al., 2021). It allows the patients to pay specific expenses which are not taxed. It comprises coinsurance and copayments, thus essential for health care delivery.
B. Restrictions of the Insurance Plans
Fee-For-Service Plans
Fee-for-service plans have specific restrictions. However, it does not restrict the patient from seeing any primary physician nationally. The major and basic fee-for-service plans limit individuals depending on the actual plans. They also restrict the out-of-pocket expenses and range within $5000 and $1000 yearly (Britton, 2015). The insurance provider takes charge of the remaining costs once the patient reaches the identified limit.
Managed-care plans
Managed-care plans also have specific restrictions. For instance, POS covers the beyond-network care while HMO does not. POS AND PPOs cover beyond-network care; however, the patient has increased financial care (Shrank et al., 2018). They are less restrictive but expensive to the patients. All the managed care plans need authorization before providing any service, and the insurance provider must give their authority for service rendering. Therefore, they are limited to specific authorities.
Government-Sponsored Health Plans
Government-sponsored health plans also vary on restrictions. For instance, in Medicare, there are specific criteria that the health experts must follow. For instance, outpatient health services are strictly covered by Medicare part B. Part A covers the inpatient hospital services. Medicare restricts coverage to strictly 190 days in psychiatric hospitals (Britton, 2015). Medicaid also has its restrictions; for instance, only low-income families can access it, depending on the state. The services, duration, or amount also varies depending on the state, which changes annually. Its restrictions are similar to the SCHIP. Lastly, TRICARE is restricted to the military. Therefore, the restrictions are vital for ensuring smooth insurance plans and healthcare service delivery.
High-Deductible Health Plans
High deductible health plans also have specific restrictions that guide the healthcare providers in using them. However, they are less restr...