A
Free-for-service plans, also known as indemnity plans are characterized by preset percentages or amounts payable to members covered. Members may pay for costs from their pockets then claim later and may also be responsible for deductibles. Managed care plans are contracts made between insurance providers and healthcare providers to offer healthcare services cheaply. Contributors in managed care plans pay less to access limited choices of facilities while they pay more to access more variety.
Government healthcare plans majorly serve the less privileged in the society such as the elderly, persons with disabilities, the poor and children among others. Government healthcare plans are funded by the Federal government. High deductible health plans are characterized with high deductibles and low premiums.
Delegate your assignment to our experts and they will do the rest.
B
Indemnity health plans do not have any restrictions but do not cover all costs of members’ medical attention. Instead, the member pays a set minimum before the insurance cover comes in (van de Ven, 2016). Restrictions in managed care plans depend on the rate of premiums paid by members. Such plans which cost less have members restricted to specific facilities while those who pay more enjoy a flexible plan free of restrictions. For government sponsored plans, they are only available to a specific group of people whose eligibility must be verified by the administrators of the various plans. High deductible health plans do not have any direct restrictions. Nevertheless, much of the initial cost of healthcare is paid by the member.
C
Most indemnity plans reimburse contributors upon payment of an annual deductible. The claim application is made with payment of deductible then the company pays the claim at a rate matching the hospital service rate. Similarly, the process of reimbursement in managed care plans commences with filled returns from the healthcare provider. The insurance provider, after receiving and approving it. Reimburse at a set rate. Government sponsored plans exist in two forms, fully sponsored for the elderly, disable among others and those that are partially funded to support low income earners. In both plans, reimbursement communication occurs between the healthcare and the government agency. High deductible plans reimbursement only kicks off when the member has paid the set deductible. The facility applies with details of the total cost and the amount paid by the contributor.
D
Various hospitals under the Inpatient Progressive Payment System get into an agreement to set rates for serving Medicare patients (McCurdy et al., 2015).Hospitals serving inpatient Medicare patients are reimbursed per-case, per- discharge. The reimbursement amount is determined by procedures per case, national set rates and market forces derived from the hospital’s geographical location. The Outpatient reimbursement prospective on the other hand, has varying rates which are determined by classification groups of payment. These ambulatory groups determine rates of payment by services and procedures.
E
The Medicare and Medicaid Patient and Program Protection Act of 1987 was put in place to execute an array of functions. This law has subsequently succeeded in dealing with kickbacks within the two government sponsored healthcare plan systems; Medicare and Medicaid. Thanks to the law, Medicare and Medicaid now do not pay entities and individuals for patient referrals. More transparency now exists in the system of reimbursement especially with regard to discounts declared by medical facilities. Generally, the two healthcare plans, Medicare and Medicaid have both had improved control system as a result of this law. On the same note, they have succeeded in saving on unnecessary costs and corruption.
F
The demonstration project involved the creation of the Audit Contractors program laid to improve the control systems in Medicare and Medicaid. Moreover, this project was created to protect hospitals and healthcare providers safeguard their incomes from Medicaid and Medicare. The demonstration project has brought about a couple of impacts. The Recovery Audit contractors have ensured that these two pair of health plans does not make inappropriate payments to healthcare providers for services they do not offer. The demonstration project has enabled Medicare and Medicaid to access all information on inpatient and outpatient services offered including the procedures underwent and the rates of service offered with reference to the national rates.
G
Both the Medicare and Medicaid Program Protection Act of 1987 and the Stark II law have impacted significantly on healthcare providers. These two set of laws have changed the way healthcare providers handle patients and subsequently improved healthcare plans. These two set of laws have specifically influenced the manner in which medical practitioners make referrals. Thanks to these set of laws, no one can influence medical referrals. On this note, healthcare provision is said to have been reformed and a strong control system laid to improve reimbursements and referrals of patients.
H
Third party payment calculations refer to the payment systems which derive healthcare costs for services offered to patients by healthcare providers. These models mostly apply where the cost of healthcare is settled by an insurance plan. Third party payment calculations come on board during application for reimbursement. These models have impacted on the healthcare systems by ensuring transparency and strict adherence to the set rates of medical services. Third party payment calculations provide solid evidence for calculations. Subsequently, the satisfaction levels of most parties in medical dealings have increased; both patients and healthcare providers have derived high level of satisfaction from the third party calculation models. Overally6, third party payment calculations have improved the process of reimbursement from health insurance plans by increasing the speed of processing and the correctness of amounts paid.
References
Gottlieb, L., Colvin, J. D., Fleegler, E., Hessler, D., Garg, A., & Adler, N. (2017). Evaluating the accountable health communities demonstration project. Journal of general internal medicine , 32 (3), 345-349.
McCurdy, D. A., Carder-Thompson, E. B., Cody, D. A., Daubert, G. L., Greeson, T. W., Pitts, P. W., ... & Narula, R. (2015). President Signs MACRA: Permanently Reforms Medicare Physician Reimbursement Framework, Includes Other Medicare Payment, Program Integrity, and Policy Provisions. Reed Smith Client Alerts .
van de Ven, W. P. (2016). Improving access to essential health care services: the case of Israel. Israel journal of health policy research , 5 (1), 3.
