How can you prevent abuses and inefficiencies in third party payments?
In the health care industry, health insurances are highly used when it comes to catering for the medical bills. However, there is an increased inappropriate payment by insurance organizations or the third party payers, which occur as a result of abuse, inefficiency, or racketeering. It is with the objective to prevent violations, fraud, and incompetence in the third payments of health insurance, that numerous methods have been discussed.
The first prevention method in place is the compliance program under the Office of the Inspector General (OIG). According to the compliance guidelines, the providers are supposed to create and dispense written comportment standards and policies to uphold the hospital’s pledge to compliance which addresses the potential areas of fraud including management of claims and other providers’ financial relationships (Xtelligent Healthcare Media, 2019). The providers should also implement continuous staff training and education to ensure they understand and can efficiently conduct health insurance operations. The compliance guidance also provides that providers should set up a system that can respond to abuse and fraud accusations and provide necessary disciplinary procedures against their staff that infringe on the policies and laws of compliance. The providers are to establish necessary processes that enable them to receive healthcare fraud and abuse complaints and ways in which the whistleblowers and anonymity can be protected.
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The second method that can be adopted to avert abuses and ineptitudes in third-party payments is employing data mining. There are different types of data mining that can be implemented to detect healthcare abuse and inefficiency. Some of them include supervised data mining, which entails approaches that apply samples of previously unknown fraudulent and non-fraudulent records. The two set method is used as construct models enabling the provider to observe the pattern of new groups of data. Through the models which require a regular update, the provider can identify a pattern of fraud and abuse behaviors in the current regulations and settings (Joudaki et al., 2014). The other type of data mining for detecting abuse and inefficiency is the unsupervised data mining methods. The unsupervised data mining methods assess attributes of one claim in comparison to other claims to establish their relation or differences from each other. The method can, therefore, provide a clear sequence and association between records and establish anomaly records providing the provider with the ability to establish possible abuse and inefficiency. The final approach for preventing violations and inadequacies in third-party payments is adopting appropriate coding, documentation, and billing processes conducted by the provider. Some of the common issues in clinical documentation and coding include undelivered services, procedures conducted that are medically unnecessary, and separate functions that are already included in a global fee.
Briefly define the flow of funds in the Care Organization.
The movement of funds within the Care Organization refers to the agreed-upon value transaction within the various kinds of partnership in health care (InsuranceNewsNet.com, Inc., 2019). Some of the examples of the partnership agreements include collaboration between an academic medical center (AMC) and a community hospital in terms of clinical. A hospital and physicians accountable care model relationship where they share the cost and quality incentive reimbursements. And a relationship between two diverse medical centers that cultivate a service line center of excellence jointly to build on the abilities of each other.
The movement of money in the care organization is provided in the diagram below (Reinhardt, 1993).
According to the diagram, the flow of funds occurs in two main procedures. The first procedure indicted as facet 1 in the diagram involves the extraction of funds from private households to collective insurance funds. The second procedure, which is indicated by facet 2, involves the process of fund disbursement to healthcare providers from the insurance fund (Reinhardt, 1993). In order to fund the health insurance fund, money can be extracted in three different ways. These include payment done directly to the insurance fund directly through private insurance purchase. Money can also flow into the health insurance fund through taxes or premiums paid by households to the public authority who place the funds into an insurance pool. Last, money is extracted from households is through private business funds which send it to the insurance fund.
Money can be disbursed from the health insurance pools to the healthcare services providers in different ways. Some of the common movement of finances from the insurance pool to the health provider includes direct reimbursements to the providers normally based on a fee-for-service arrangement and flow of funds through the capitated managed care networks who then send the payment to an individual’s provider on variety of bases such as capitation, fee-for-service, or per diem for inpatient services.
What challenges do consumers face who are enrolled in private insurance?
There are numerous challenges that consumer enlisted in private insurance have to deal with. Some of these challenges include the high cost of individual health insurance, which continues to deepen due to changes in the federal level, creating anxiety into the insurance markets. The consumer in the private insurance rarely receives help from the insurances in terms of shopping for coverage since there is reduced support from the federal government in terms of collecting ACA exchanges (Rosato, 2018). With the federal government not receiving the money promptly; the private insurers tend to hesitate in providing insurance to more expensive sicker customers, and there is weaker protection of consumers enrolled in the private insurance due to lack of protection for customers with pre-existing health conditions.
The other challenges that consumer enrolled in private insurance are information access frustration. A consumer finds it hard to completely access their full health records due to different or separate portals that manage their local hospital, specialist, and primary care physicians (South, 2017). There is also a challenge of understanding the new benefits arrangements due to overwhelming benefit navigation. For examples, some private insurance directly define contribution plans, which increases pressure on consumers.
What methods can you use to empower the consumer?
Insurers can implement different methods to ensure that their consumer feels they are in charge and have everything in control. The methods can provide the consumers with resources, incentives, and tools to enhance their health. Some of the approaches that can be adopted to empower the consumers include understanding benefits, which involves helping consumers to make wise and informed decisions. The insurers have developed tools which help them in providing necessary information to the consumer that helps them make their choices based on their health statuses, preferences, and the options available to them. The other consumers the best empowering method is enhancing price transparency (Overland, 2014). The price transparency improving practice involves helping consumers make more informed decisions by organizing costs, benefits, and quality of various healthcare procedures and services. Also insurers may empower consumers through effective management of the controllable health sector. Since a vast majority of consumers tend to have preventable or manageable conditions, the encouragement from insurers to such consumers to actively manage their condition through goal settings, personal performance monitoring, and providing the consumers with social support.
A provider directory which offers a listing of clinicians, physicians, pharmacies, and facilities attached to the health plan is provided to the consumers as an empowering method. The provider directories can also include provider specialty and address. The convenience factor in insurance has become essential due to the growing population, technology, and lack of time for consumers to conduct all required procedures to be ensured manually. Therefore, to empower consumers, the use of mobile apps is the key to convenience as it enables the consumer to conduct several tasks at their figure prints. Some of the benefits of mobile apps include making an appointment to connect with a doctor, information viewing, and appointment scheduling (AHIP, 2018). Lastly, it ensures it empowers consumer through programs such as health assessment and reward programs. Health assessment and reward programs provide support to lessen an individual burden accumulated due to the health care crisis.
References
AHIP. (2018). How Health Insurance Providers Empower Consumers . Retrieved from https://www.ahip.org/how-health-plans-are-empowering-consumers/
InsuranceNewsNet.com, Inc. (2019). Funds flow in the era of healthcare transformation . Retrieved from https://insurancenewsnet.com/oarticle/funds-flow-in-the-era-of-healthcare-transformation#.XPFEV9IzZpg
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2014). Using data mining to detect health care fraud and abuse: a review of literature. Global journal of health science , 7(1), 194–202. doi:10.5539/gjhs.v7n1p194
Overland, D. (2014). Payer 3 ways to empower consumers. Fierce Healthcare . Retrieved from https://www.fiercehealthcare.com/payer/3-ways-to-empower-consumers
Reinhardt, U. (1993). Reorganizing the Financial Flows in American Health Care. Journal of Health Affairs . Vol. 2, No. SUPPL 1. https://doi.org/10.1377/hlthaff.12.suppl_1.172
Rosato, D. (2018). Cost of Individual Health Insurance Depends More Than Ever on Where You Live. Consumer Reports . Retrieved from https://www.consumerreports.org/health-insurance/cost-of-individual-health-insurance-depends-more-than-ever-on-where-you-live/
South, K. (2007). Top 3 challenges facing healthcare consumers. Allscripts . Retrieved from https://www.allscripts.com/news-insights/blog/blog/2017/04/top-3-challenges-facing-healthcare-consumers
Xtelligent Healthcare Media. (2019). How Providers Can Detect, Prevent Healthcare Fraud and Abuse . Retrieved from https://revcycleintelligence.com/features/how-providers-can-detect-prevent-healthcare-fraud-and-abuse
