732.2.1: Reimbursement Methodologies – The graduate describes and compares contemporary healthcare reimbursement methodologies and systems utilized in the United States.
732.2.3: Voluntary Healthcare Insurance Plans and Managed Care -The graduate describes key components of private, commercial, and Blue Cross and Blue Shield insurance plans and evaluates how various insurers use coding in the billing process.
732.2.4: Government-Sponsored Healthcare Programs—Including Medicare and Medicaid – The graduate evaluates and explains various government-sponsored healthcare programs and recognizes the impact that government-sponsored healthcare programs have on the healthcare system in the United States.
732.2.5: Government-Sponsored Healthcare Programs—Other Components and Methods – The graduate evaluates and explains components and methods of non-Medicare/non-Medicaid government-sponsored healthcare programs; and recognizes the impact that government-sponsored healthcare programs have on the healthcare system in the United States.
732.2.6: Ambulatory Reimbursement Systems – The graduate evaluates and explains the structures and components of and performs payment calculations for outpatient healthcare reimbursement in healthcare
The healthcare reimbursement system in the United States is complex. The health informatics 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 and Blue Cross and Blue Shield plans offer a different menu of options to their clients. One issue is certain: All third-party payers are interested in decreasing healthcare costs while improving quality and controlling access to unneeded services.
This task will allow you to examine the complexity of the healthcare reimbursement systems and begin to compare the similarities and differences between them. To complete this task, read the attached “A Lifetime of Healthcare Services,” which is a case scenario about a woman named Sophie. Then create a multimedia presentation, diagram, table, or other illustration comparing the differences and similarities among the various insurance options and reimbursement systems that were used to pay for Sophie’s medical care throughout her lifetime.
You are explaining these reimbursement systems from the perspective of a billing department manager training two new staff members. You believe that if you can explain these systems with a real patient, it will be easier for your new staff to understand the various requirements of these reimbursement systems.
A. Compare Sophie’s health insurance options for each of the five phases of her life.
1. Recommend the health insurance option that would provide the best coverage to meet Sophie’s needs during each phase.
a. List the elements of each plan you recommended.
b. Discuss the reimbursement requirements of each plan you recommended.
c. Discuss restrictions to each plan you recommended.
B. If you use sources, include all in-text citations and references in APA format.
Attachment: A lifetime of Healthcare Services
A Lifetime of Healthcare Services
When Sophie was first married, her husband worked in a meat packing plant. His job
offered an optional health insurance package that could cover Sophie’s husband, Sophie,
and their family. Sophie did not have a job; she stayed home to care for their five children
and an elderly parent. Many years passed. Sophie and her husband raised their children,
and her elderly parent died. Sophie’s husband looked forward to retirement.
Sophie’s husband died before he reached retirement age. His company offered his benefits
plan to Sophie, which she could enroll in indefinitely if she chose to do so. This plan would
include good drug benefits. The insurance plan through the company had become a
managed care plan over the years. Sophie decided to remain with her husband’s insurance
Sophie turned 65. She was on a tight budget and did not like the idea of paying a monthly
premium. However, she wanted her insurance to provide many physician and service
options. She also wanted a good drug coverage plan.
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