Third-Party Payment Systems and the Operational and Strategic Planning Research Paper

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IV. Third-Party Payment Systems:

1. a) Healthcare System Reimbursement: Evaluate third-party payer models for the impacts they present on healthcare system reimbursement.

Third-party payment has had a major impact in healthcare system through the aspect of increased demand and in so doing driven up prices. In particular, medical suppliers that deal with comparatively low levels of third-party payment have experienced considerably lower price upsurges in the course of time. The Patient Protection and Affordable Care Act (PPACA) has augmented the practice of high-deductible insurance, but has other features that work against cost suppression and control. In addition, the third-party payer models have also facilitated faster and easier payment practices for healthcare services rendered (Buff and Terrell, 2014).

2. b) Reporting Requirements: Analyze the reporting guidelines of third-party payer payment systems. What opportunities and challenges do they present for healthcare leaders in meeting reporting requirements?

There are opportunities presented to healthcare leaders is that there is the ability of fast, comprehensive assessment of prospective misconduct of corporate officers who can influence billing decisions. There is the quick detection as well as reporting and this diminishes the loss incurred by third-party payers from false claims. In addition, it is possible to augment the structure of the billing of the corporation’s operations and consistency between different business units. There are also challenges that come about. One of the challenges takes into account the fear and hesitation be personnel in reporting any issues and problems that come about. In addition, having a centralized system can limit the effectiveness of the payment systems in different units (Office of Inspector General, 1998).

3. c) Compliance Standards and Financial Principles: Analyze how healthcare organizations in general utilize financial principles to guide strategic planning to ensure the meeting of third-party submission requirements.

One of the ways is to ensure that the emphasis is shifted from the products and services rendered to the client.

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The focus is on how the services are transmitted to the client and their experience. What matters is patient satisfaction. Another aspect is being compliant to the set rules and regulations to ensure that when requests are made, they have complied and adhered to the regulations agreed upon (Perera and Peiro, 2012).

4. d) Reimbursement Methods: Considering third-party payer systems, what strategies would you recommend organizations implement in order to receive full reimbursement on claims as well as to improve timeliness of this reimbursement? Be sure to justify your recommendations.

One of the strategies is episode-of-care payment which makes it possible for providers to delineate a single, wide-ranging price for an episode of care, which as a result would facilitate payers to have faster and quicker perception of the complete cost of treatment and to more precisely match the costs of dissimilar providers that could provide the same treatment (Olsen et al., 2010). Bundled payment is another strategy and is beneficial because its execution does not necessitate any form of organizational change to the delivery system; it would basically necessitate an act of collaboration in the prevailing system (Olsen et al., 2010). 

V. Operational and Strategic Planning in Healthcare:

1. a) Pay-For-Performance Incentives: Based on your prior analysis of the impact of case rates and management utilization data on pay-for- performance incentives, recommend appropriate operational strategies to improve performance measures that will maximize reimbursement. Be sure to provide support for your recommendations.

The following are suitable operational strategies to enhance performance measures:

i. Integrating care delivery systems: To achieve spot-on system integration, organizations must contend with four associated groups of choices including describing the scope of services, focused volume in smaller number….....

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