d)
Government Payer Types
There are strategies that I would recommend as the Administrator of our hospital to
implement in order to receive full reimbursement on claims. One strategy is to double-check
errors and claims through an automation system (Tohill, 2016). Another strategy is on-
going
training for all billing staff to stay ahead of ongoing changes in the healthcare field. Also better
management of denied claims will improve reimbursement. “Most claims are denied due to
minor details. Train your staff, your providers and everyone else who impacts billing to complete
forms accurately, legibly, and without error” (2016). The billing department will be managed by
a daily management system to ensure proper measureable rates. This will also allow for
immediate investigation of denials (2016).
8
IV. Third-Party Payment Systems
a)
Healthcare System Reimbursement
Third-party payer models pay for services to the hospital or provider and can include
Medicare or health insurance companies (Casto & Forrestal, p. 8). Third-party payer models
have various impacts on reimbursement. There are financial risks for all models including
determining payment for each service, time orientation, and projected costs (p. 8). “The account
receivable department manages the amounts owed to a facility by customers who received
services but whose payments will be made at a later date by the patients or their third-party
payers” (p. 255). The impact of time is present during this phase of reimbursement. The longer
the time frame, the less likely the provider or hospital will get paid (p. 255). Third-party payer
systems also impact consumers by raising prices as demands increase.
b)
Reporting Requirements
“Well designed and complete policies and procedures provide employees with consistent
guidance to perform their assigned task” (Casto & Forrestal, p. 44). Without reporting guidelines
mistakes will happen. When mistakes happen, the hospital or provider may find themselves
involved with compliance issues. The opportunities that reporting guidelines present for leaders
is lower costs and lower prices for consumers. The threats present for leaders is the fear of
reporting the problems as they arise.
c)
Compliance Standards
In general, financial principles are utilized to guide strategic planning to ensure submission
requirements through highly regulated processes. This is regulated through many different
agencies and organizations like the Joint Commission. It is the mission of the Joint Commission
to “continuously improve health care for the public, in collaboration with other stakeholders, by
evaluating health care organizations and inspiring them to excel in providing safe and effective
9
care of the highest quality and value” (The Joint Commission, 2019).
Financial principles
include following a strict pay model, preventing malpractice and providing less incentives for
doctors. The goal is to focus on quality of care rather than quantity of care.
