Instructions
Healthcare is reimbursed in a variety of ways. The prospective payment method is one of those ways. This paper will be about the prospective payment method where diagnosis-related groupings (DRGs) forms the basis for payment.
Research and explain the origin, purpose, and description of DRGs.
Include what payment is based on.
Identify the benefits and problems with reimbursement via this method.
Explain how you as a nurse-manager can help manage costs and maximize your facility’s reimbursement from
DRGs.
The paper should contain an opening, a body, and a conclusion, and be 3-4 pages long.
3-4 professional references are required.
Introduction
Healthcare reimbursement entails the nature of payment usually received by hospitals, diagnostic facility, healthcare provider and other healthcare entities after they have provided medical services to patients or clients. To date, various healthcare reimbursement models have been used to achieve the end. In most cases, the payer usually covers all or some of the healthcare costs while in some cases, the patient also covers part of it (Chen et al.,2020). However, in the case where a patient has no health insurance, then they have to cover all the costs for the healthcare services provided. It is important for healthcare professionals to understand the healthcare reimbursement models. Therefore, this presentation focuses on a healthcare reimbursement training.
Medicare Reimbursement
One of the reimbursement strategies currently in use is Medicare reimbursement. Medicare is mainly known to be a program for individuals of at least 65 years of age. However, it is also cover particular people below sixty five years with disabilities. The implication is that individuals below sixty five are included in the program under special considerations. While it has several parts, Medicare is has two major parts. The program has various parts such as hospital insurance, also known as part A and medical insurance, also known as part B (Duncan et al.,2020). Part A covers various aspects such as home health services, hospice care, skilled nursing facilities and inpatient hospital care. On the other hand, Part B covers durable medical equipment, physician services, and outpatient services. There are also parts C and D. Part C is known as Medicare advantage and offered by private insurance companies approved by Medicare. Part D covers prescription drug coverage through private insurance plans. These parts direct the reimbursement process.
As earlier indicated, the Medicare parts direct the reimbursement process. In part A, the healthcare organizations offering patient services are reimbursed through the prospective payment system. This system entails reception of a fixed amount for specific services offered without considering the actual costs. In part B of Medicare, the reimbursement is done on a fee-for-service basis (DeCherrie et al.,2021). This strategy involves setting a fee schedule, hence the healthcare entities are paid depending on the services they offer. However, such payment depends on coinsurance and deductibles. Part C reimbursement is based on capitated payments, meaning that the government pays an amount for a beneficiary to a private insurance. Finally part D reimbursement involves a combination of beneficiary premiums and government subsidies. As such, the government offers subsidies for drug costs for the beneficiaries.
Medicaid Reimbursement
As earlier indicated, the Medicare parts direct the reimbursement process. In part A, the healthcare organizations offering patient services are reimbursed through the prospective payment system. This system entails reception of a fixed amount for specific services offered without considering the actual costs. In part B of Medicare, the reimbursement is done on a fee-for-service basis (DeCherrie et al.,2021). This strategy involves setting a fee schedule, hence the healthcare entities are paid depending on the services they offer. However, such payment depends on coinsurance and deductibles. Part C reimbursement is based on capitated payments, meaning that the government pays an amount for a beneficiary to a private insurance. Finally part D reimbursement involves a combination of beneficiary premiums and government subsidies. As such, the government offers subsidies for drug costs for the beneficiaries.
The next reimbursement strategy is Medicaid reimbursement. This is a joint state and federal program focused on offering health insurance to people hailing from low income families or those with low incomes. The medical reimbursement used in Medicaid has for a long time been labeled as complex. It is also important to note that its not uniform but may vary from state t
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