The current healthcare system has been revamped with many reforms and policies that aim to better consumer experiences when receiving health services. Among these policies is the Affordable Care Organization (ACO). The main goal of ACO is to ensure patients receive quality care at affordable rates. However, due to the ACO reform numerous insurance companies (or third-party payers) have emerged, which has led to the complete elimination of private pay. In turn, this has led to numerous changes occurring in the flow of funds in health care settings. The flow of funds can be defined as the movement through which income generated by a healthcare organization is apportioned and distributed through the varying departments, factions, and units in the setting (Patel et al, 2014). In simple terms, the flow of funds defines the overall inflow and outflow of resources in the organization. Various issues are associated with how funds flow through a healthcare organization. The following discussion is written to present an in-depth analysis and evaluation of the flow of funds within a healthcare organization to help in better understanding the topic. The paper will focus on third-party reimbursements and private pay as the modes of payment influencing the flow of funds in a healthcare setting
In a healthcare institution, funds mainly come in through payments that clients give after receiving services. These payments are mainly received through private pay or third-party reimbursements. Private pay entails a situation whereby the patients opt to take care of all the bills accrued by themselves rather than using a medical cover. On the other hand, a third-party reimbursement is whereby an insurance company sorts out a patient’s bills after receiving treatment. These two payment methods represent the main medium through which funds are channeled into a hospital’s account. The flow of funds within a health setting is mainly measured once every month or every quarter of a year. After reviewing the funds' flow reports, an organization can understand the changes experienced from the beginning to the end of a financial year and its overall working capital. Therefore understanding the way that funds flow in an organization is crucial in determining its success in terms of revenue generation.
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Third-party payments from insurance companies have been marred with irregularities such as fraud, abuses, and inefficiencies. However, several techniques can be used to reduce or prevent these negative aspects associated with third-party reimbursements. Already huge resources are being allocated in strategizing reliable ways that will help in achieving the objective of preventing these irregularities. One of the verified methods that can help in preventing these inefficiencies involves the use of knowledge discovery from available databases. The strategy above is a key approach that integrates statistical techniques with programmed methods to help in the extraction of a client’s data for extensive assessment. The use of the above approach is referred as data mining (Joudaki et al., 2016). Data mining helps the insurance company in affirming whether the claim made by a subscriber is true or false. The insurance company can only proceed to make the payment after ascertaining the accuracy and truthfulness of the information provided. Therefore, data mining is critical in reducing payment inefficiencies that are currently being experienced in the care provision system.
Another viable technique that can be used in the prevention of third-party payment inefficiencies involves a stepwise model that is focused on reducing the wastage of resources (Joudaki et al., 2016). Employing this model will not only improve the delivery of care services and payments made through third-party reimbursements but will also ensure effective cost management is upheld. The model will purpose on strengthening the relationship ties between third-party payers and the health institutions hence limiting the probability of fraud occurring. Subsequently, this will ultimately result in the proper management of resources.
There are various challenges faced by consumers who have subscribed to private insurance options. A huge fraction of consumers who are enrolled in these services faces the challenge of losing financing on medical insurance exchanges. Health insurance exchanges were implemented during the enacting of the Affordable Care Act. However, these health insurance exchanges have significantly failed to act as a favorable market for individuals who are enrolled in private insurance. The reason being that the policies provided in the ACA directly affect the actions of private payers by calling for expensive care from the providers (Patel et al, 2014). In turn, it results in huge financial loses for the consumers which prove to be a major challenge. Another challenge is the lack of sufficient knowledge and understanding of the services provided by private entities among consumers. The result of this is that the companies end up taking advantage of the consumers by maximizing the revenue that they earn from their subscribers through unscrupulous methods while failing to satisfactorily fulfill their responsibilities.
Several proven methods can be used in the empowering of the consumer. In fact, consumer empowerment and engagement are pivotal elements in the healthcare provision model. Consumer empowerment leads to positive patient behavior and collaboration between the caregivers and their clients. One main method that can be used to achieve consumer empowerment involves promoting consumer literacy about the services offered in the health sector (Joudaki et al., 2016). Consumer literacy can be achieved by using platforms such as blogs and articles to educate the clients based on services offered in healthcare, their responsibilities, and their rights while receiving care.
Consumers can also be empowered by helping them comprehend what they hear from the medical practitioners on matters that relate to their health or the services they receive. The above can be accomplished by using patient-friendly methods and simple terms that will help them in understanding what they are experiencing while in a healthcare setting. The driving point of this notion is founded upon the principle of patient-centeredness (Joudaki et al., 2016). Effective patient-centeredness acts as a foundation in attaining consumer empowerment. Designing healthcare strategies or policies with the involvement of the consumer is also crucial in attaining consumer empowerment. Involving the opinion and input of the patients while designing strategic policies in a healthcare organization will play a vital role in ensuring that consumers are empowered and patient engagement is upheld.
In conclusion, it is evident that the flow of funds within an organization involves a complex and intricate process that needs prudent handling to ensure success. A major factor in the flow of funds entails the third party reimbursements option. Despite its issues, the option contributes greatly to ensuring the fluid flow of funds and resources in the organization. Employing the approaches mentioned above will play a significant role in preventing these inefficiencies and improving the quality of services that patients receive in health settings. Ensuring consumer empowerment is also key to achieving care success and quality. Therefore, healthcare institutions should choose to empower their consumers, which will improve the overall benefits of care organizations.
References
Joudaki, H., Rashidian, A., Minaei-Bidgoli, B., Mahmoodi, M., Geraili, B., Nasiri, M., & Arab, M. (2016). Improving fraud and abuse detection in general physician claims: a data mining study. International journal of health policy and management, 5(3), 165.
Patel, N. J., Deshmukh, A., Pant, S., Singh, V., Patel, N., Arora, S. & Parikh, V. (2014). Trends of hospitalization for atrial fibrillation in the United States, 2000 through 2010: implications for healthcare planning. Circulation, CIRCULATIONAHA-114.
