Final Project: Analysis and Report Page 1
Patrick Kirby
Southern New Hampshire University
IHP 630
Final Project: Analysis and Report
Final Project: Analysis and Report Page 2
Introduction:
Third-party payers are those who reimburse the providers for the services provided.
Providers must submit claims correctly and in a timely fashion in order to be fully reimbursed.
Communication throughout a healthcare organization is essential in order to ensure that staff
correctly submit these claims in order to be reimbursed for all services rendered.
Reimbursement Strategies:
The case-based payment method allows providers to be reimbursed for each patient who
fall under a certain pre-established condition (Casto, & Forrestall, 2015).
These conditions are
can be seen through the Medicare-severity diagnosis-related groups, or MS-DRGs, which
established how much money is needed, on average, to treat patients with certain conditions or
diseases (Casto, & Forrestall, 2015). This payment method has third-party payers reimburse
providers based on each case instead of each service provided (Casto, & Forrestall, 2015).
This
gives providers the incentive to provide quality services for the amount they are reimbursed
because they get the amount leftover rather than providing expensive treatments to be
reimbursed the most such as in a fee-for-service reimbursement schedule (Casto, & Forrestall,
2015).
If providers provide more services than needed for each case, they lose money.
This
promotes quality care while aiming to keep health care costs down.
Reimbursement Methods:
Fee for service reimbursement charges for each service provided to a patient (Casto, &
Forrestall, 2015). Most physicians and healthcare organizations use this method of
reimbursement in the United States (Casto, & Forrestall, 2015). The advantage of this
reimbursement method is that it allows patients to choose where they would like to go for
Final Project: Analysis and Report Page 3
services (Casto, & Forrestall, 2015). This may be advantageous if patients have a physician that
they would prefer to see.
This gives the patient freedom to go to any healthcare facility they
choose.
The disadvantage of this is that it can promote overutilization of services to that
providers get the most payment (Rajpal, Peruchi, & Sawhney, 2013). Another disadvantage is
that it has higher deductibles and copayments for patients than other plans such as managed care
plans (Casto, & Forrestall, 2015).
Managed care reimbursement is advantageous as it provides case-based payments to
providers by average cost of disease by classification and controls costs by limiting
overutilization by capitating costs so that patients do not receive extra services just, so providers
can get greater payment (Casto, & Forrestall, 2015). This reimbursement method is
advantageous because patients much choose a primary provider to help coordinate all treatment
decisions based on need rather than adding more expensive treatments like in fee-for-service.
