reimbursement systems

The healthcare reimbursement systems in the United States are complex. A health information management professional needs an understanding of the basic principles of the third-party payer system and the many options that are available to citizens through government-funded healthcare programs. Private and commercial insurance companies offer a different menu of options to their clients. All third-party payers are interested in decreasing healthcare costs while improving quality and controlling access to unneeded services.

In this task, you will examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete this task, you will discuss each type of healthcare insurance plan listed, as well as the plan components, reimbursement provisions, restrictions, and the impact of government regulations.

REQUIREMENTS

Your submission must be your original work. No more than a combined total of 30% of the submission and no more than a 10% match to any one individual source can be directly quoted or closely paraphrased from sources, even if cited correctly. An originality report is provided when you submit your task that can be used as a guide.

You must use the rubric to direct the creation of your submission because it provides detailed criteria that will be used to evaluate your work. Each requirement below may be evaluated by more than one rubric aspect. The rubric aspect titles may contain hyperlinks to relevant portions of the course.

A. Discuss the components of each of the following insurance plans:

• Fee for service (indemnity) plans

• Managed care plans

• Government-sponsored health plans (i.e., Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).

• High-deductible health plans/healthcare savings accounts

B. Discuss the restrictions of each of the following insurance plans:

• Fee for service (indemnity) plans

• Managed care plans

• Government-sponsored health plans (i.e., Medicare, Medicaid, State Children’s Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).

• High-deductible health plans/healthcare savings accounts

C. Discuss the reimbursement process for each of the following insurance plans:

• Fee for service (indemnity) plans

• Managed care plans

• Government-sponsored health plans (i.e., Medicaid, State Children’s Health Insurance Program (SCHIP), Military/TRICARE, Indian Health Service).

• High-deductible health plans/healthcare savings accounts

D. Discuss the inpatient and outpatient reimbursement processes for Medicare.

E. Analyze the impact the Medicare and Medicaid Patient and Program Protection Act of 1987 had on Medicare and Medicaid.

F. Analyze the impact the Recovery Demonstration Project had on Medicare and Medicaid.

G. Analyze the impact of anti-kickback statutes of both Stark II and the Medicare and Medicaid Program Protection Act of 1987 on healthcare providers.

H. Discuss how third-party payment calculations impact healthcare reimbursement in healthcare organizations.

I. Acknowledge sources, using APA-formatted in-text citations and references, for content that is quoted, paraphrased, or summarized.