Another method is Managed Care, which has become an answer to the flawed Fee-For-
Service method. Managed Care seeks to control costs and concentrate on the quality of care, with
Casto and Forrestal (2015), noting that bundled payments decrease patient’s fears of increased
payments for multiple services, and offers incentives for staying in-network. Staying in-network
garners loyalty to your selected facility and the physicians included in your care plans. Moving
towards value-based care is not one size all and allows for providers to use benchmarks to be
assessed and evaluated throughout the year.
Reporting Requirements
Reporting for third party payers for reimbursement is very similar to the requirements for
government payer types
as both types are eligible for incentives based on performance and
quality of services. Private payers such as Anthem or United Health Group, each charge per
service and situation and has its own set of guidelines and rules for each area. As mentioned
above, LaPointe (2017), noted that Medicare denies about 5 percent of claims, whereas private
payers try to stay below 5 percent with Anthem reporting the highest amount at 2.64 percent.
Many challenges and opportunities regarding payment guidelines for private third-party
payers exist, and it is imperative for healthcare facilities to understand both state and federal
requirements, as the guidelines may differ. Crocker (2006), explains that in a constant changing
healthcare landscape, the only way to appropriately manage a facility’s revenue cycle is to
constantly monitor all aspects of the cycle from registration to a zero-balanced out account.
Consistent monitoring and evaluation will help all departments work conjointly throughout all
ANALYSIS AND REPORT
12
aspects of the revenue cycle, which can identify errors well in advance to submission. Ensuring a
clean claim submission will lessen to number of denials, however, the challenge lies in changes
to the industry such as reduced reimbursement in both government-sponsored and private
contracts.
Compliance Standards
Financial management is an area that requires skilled personnel and in healthcare, it is
even more important to have staff well versed in the billing and claims cycle, as well as financial
operations and policies. The Health Information Technology for Economic and Clinical Health
(HITECH) Act, a part of the American Recovery and Reinvestment Act of 2009, was presented
to promote the adoption and meaningful use of health information technology. The Department
of Health and Human Services (HHS) (2017), states there are four categories of violations and
four matching tiers of penalty amounts that increase with each violation towards a maximum
amount of $1.5 million. This can be a detrimental to any medical center and can impact the
overall quality of care and resources that a facility needs in terms of equipment and training.
