Working Within The Workers ' Compensation Essay

Working Within The Workers ' Compensation Essay

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Working within the workers’ compensation (WC) structure in cost and billing is different than the Affordable Care Act (ACA) reimbursement system. Prior to taking the Healthcare Business Dynamics class, I understood the different WC medical care pay schedules according to each state; albeit, participating in the strategic planning of a business plan, I have a better understanding that Medicare, Medicaid, and group insurance is reimbursed at a lower rate causing concern that the AFA may cause financial distress on the healthcare institutions (Aldhizer & Juras, 2015). Thus, hospitals and insurance companies continue to think like a business versus a service provider because they do not want to cover pre-existing conditions or be held accountable to meet required outcomes to receive reimbursements (Aldhizer & Juras, 2015). In comparison, WC medical care services is paid up to the 90th percentile of billed costs (Barbour, 2016). And, states with lower expenditures in group health insurance have a higher usage of workers compensation insurance; in contrast, states where medical services have a higher payout with group insurance, they have a reduction in workers’ compensation medical care utilization (Stahl, 2013). The gap in medical service charges within the WC system is related to the failing injury care due to overtreatment and the lack of accountability in meeting medical care outcomes (Stahl, 2013). The ACA’s standard requirements for positive outcomes to receive reimbursement is the strongest asset in healthcare delivery. Albeit, to provide quality and safe care for the injured worker, WC necessitates adaptation in producing results in services to decrease the disparity in care (Stahl, 2013).
Strategic planning participation in th...


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...tion, lost work days, and a decrease in specialty referrals, and claim costs compared to the ODGs on an annual basis for insurance year (Tomlinson, 2015).
In January during our yearly risk management meeting in Chicago, I will present the NCM utilization strategy and propose using a NCM at the beginning of each claim while implementing the six criteria to improve the quality and safety in employee medical care following an injury, and that collaboration with the doctor, patient, and employer promotes excellent medical outcomes, return to work, and a decrease in disability (Diffenderfer, 2015). The project will be marketed internally, to colleagues in the risk management team, to explain how this project falls in line with our purpose to care and show compassion to our injured employees while achieving strategic purpose within the organization (Differderfer, 2015).

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