The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care. Quality patient care is an ongoing endeavor that involves many different areas of healthcare. One area of healthcare that is often employed is Utilization Management. We read in John’s that UM “is composed of a set of processes used to determine the appropriateness of medical services provided during specific episodes of care” (John,2011). Things that are used to determine the appropriateness of care include the patient’s diagnosis, site of care, length of stay, and other clinical factors. This system consists of three main functions aimed at improving patient care and controlling healthcare costs. These functions include utilization review, case management, and discharge planning. One source states that it also includes the claim denials and appeals process (Interviewee C. Jarvis, e-mail communication, May 3, 2014). When used correctly, these UM processes can expedite the patient’s care and reimbursement. It also demonstrates to third party payers that the organization is taking measures to help control costs. This monitoring and management of patient healthcare needs ensur... ... middle of paper ... ...that can be conducted by other qualified professionals which will provide them with more time to devote to patient care. This use of HIM professionals in the UM process establishes a new area that organizations can capitalize on to improve the patient care. Works Cited American College of Emergency Physicians. (2014, April). Utilization Review FAQ. Retrieved from https://www.acep.org/Clinical---Practice-Management/Utilization-Review-FAQ/ Jeffries, M. (2007, October). Utilization Review. How Stuff Works. Retrieved from http://health.howstuffworks.com/health-insurance/utilization-review.htm Johns, M.L. (2011). Health Information Management Technology An Applied Approach (3rd Ed). AHIMA Press Miller, J. (2013). Payers rethink utilization costs. Managed Healthcare Executive, 23(11), 9-9,15. Retrieved from http://search.proquest.com/docview/1458614037?accountid=36202
In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. This drives up costs by rewarding providers for doing more, even when it’s not needed. ACOs continue to utilize fee for service by creating incentives to be more efficient by offering bonuses when providers keep ...
Miller, H. D. (2009). From volume to value: better ways to pay for health care. Health Affairs
Healthcare providers must make their treatment decisions based on many determining factors, one of which is insurance reimbursement. Providers always consider whether or not the organization will be paid by the patients and/or insurance companies when providing care. Another important factor which affects the healthcare provider’s ability to provide the appropriate care is whether or not the patient has been truthful, if they have had access to health, and are willing to take the necessary steps to maintain their health.
Achieving high value for patients must become the overarching goal of health care delivery, with value defined as the health outcomes achieved. ( Michael E. Porter, 2010).
Throughout their research they compared a few different hospitals, finding evidence that Clinical Decision Unit’s (CDU) had a large influence on the readmission rates of these patients. CDU’s improve the overall quality of the patient
Managed care reimbursement models have contributed to risk avoidance by negotiating discounts, discouraging use, and denying payments for charges that appear to be false. Health care reform has increased awareness to the quality of care providers give, thus shifting the responsibility onto the provider to provide quality care or else be forced to receive reduced reimbursements (Buff & Terrell,
Case 1 -- You work in a busy multi-specialty clinic with a high patient volume. The physicians enter the type of code that will yield the greatest reimbursement. You suspect the codes are not accurate.
In recent times, healthcare organization across the nation are facing unprecedented challenges as they strive to improve the overall quality of care provided to their patient’s population, while improving their organization’s financial performance. Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations.
Levit, K. R., & Cowan, C. A. (1991). Business, households and governments: Health care costs, 1990. Health Care Financing Review, 13 (2), 83. Retrieved from: Ashford University Library
Satisfying patients is the top priority for healthcare administrators who are interested in improving the performance of the organization, preventing patient claim, leveraging on reimbursement and increasing gains in terms of the reputation as health providers of choice. The specific measures attributed this noble endeavor include waiting time, interaction with personnel, food, facility, access to information, inculcated programs and activities as well as perceived costs in relation to the quality of services delivered. In order to ensure quality of service and work towards improving the overall level of patient satisfaction, it is imperative for medical practitioners and other stakeholders to understand the above key measures and most importantly be able to make them a priority in all their practices. On the other hand, it is important to understand that patient satisfaction is a long-term process which takes concerted effort to achieve. Therefore, every instance should be a learning point where the focus should be on improving what is there presently to achieve higher standards
Reimbursement programs are a part of the United States health care system and they represent a financial tool for providing cash flow to service physicians and hospitals. Often times, the competency to provide quality health care is to be contingent on the payment for the services given by physicians and hospitals. Physicians that take part in the managed care systems are reimbursed by several different methods for their services. The two most common methods are Fee-For-Service or Capitation. Managed health care has grown considerably within the health care industry and Physicians have faced several challenges in establishing and financing payment systems for services. On the daily in the news you will see or hear about the financial savings resulting from managed health care as well as the restrictions on patient freedom. Insurance risk seems to be one of the less talked about concerns in the movement toward providing health care and professionals often ponder about who should bear the risk of insurance fees. For providers reimbursement is an essential portion of the managed care system. In order for them to receive their incentives to provide that efficient quality care they need to be reimbursed
Among them is its emphasis on productivity. Fee for service encourages the delivery of care and maximizing patient visits. As a payment mechanism, it is relatively flexible in that it can be used regardless of the size or organizational structure of a physician’s practice, the type of care provided such in clinic visit, surgery, therapy session, and the place of service such as physician’s office, nursing home, hospital, surgery center or the geographical location of care. Fee for service does support accountability for patient care, but it is often limited to the scope of the service a particular physician provides at any point in time. Although fee for service is easy to understand conceptually, it can be difficult to understand in practice. Patients may struggle to decipher the coding and nomenclature involved in billing, manage the numerous bills and explanations of benefits they might receive, and understand its application in inpatient settings, especially for lab, radiology, and anesthesia services. Because payment is limited to one provider for one interaction, fee for service does little to encourage management of care across settings and among multiple
Thanks for your informative post, true with the managed care under so much pressure to reduce the costs of their customers’ health care, it is not surprising that Utilization management is gaining popularity not only within the managed care arena but, also within the entire health care industry. The concept of utilization management as has been echoed in various discussions this week is based on encouraging the highest quality of care, in the most appropriate setting while containing the costs of health care. In a nutshell, UM is looking to avoid overuse and underuse of care or services by beneficiaries or providers. Because the utilization management includes a range of processes, its application can be utilized prior
New developments have changed the way health care operates. The government is buying the concept of effective economies of scale much more fervently because Medicaid has drastically increased the area of individuals under the mandatory insurance. Therefore, paying for the actual performance of diagnosis and treatment rather than the service of medical procedures has gained prominence in the place of thorough, but often unnecessary medical procedures. The discussion highlights the problem then goes on to a propose logic model to address the issue. Cost is one of the main barriers to health care in America. The discussion focusses on how to make the processes of health care more cost-effective without increasing premiums or compromising on quality.
...d procedures are now being monitored to improve clinical processes. Ensuring that these processes are implemented in a timely, effective manner can also improve the quality of care given to patients. Management of the processes ensures accountability of the effectiveness of care, which, as mentioned earlier, improves outcomes. Lastly, providing reimbursements based on the quality of care and not the quantity also decreases the “wasting” and overuse of supplies. Providers previously felt the need to do more than necessary to meet a certain quota based on a quantity of supplies or other interventions used. Changing this goal can significantly decrease the cost of care due to using on the supplies necessary to provide effective, high-quality care. I look forward to this implementation of change and hope to see others encouraging an increase in high-quality healthcare.