Question

You are a newly hired HIM professional and you have been assigned to spend time with an HIM student who is participating in their professional practice exercise (PPE). The student needs to learn about the following types of reimbursement methodologies

ACO's (Accountable Care Organizations).

Fee-for-service (including self-pay, traditional retrospective payment, and managed care)

Episode-of-care (capitated payment, global payment, and prospective payment)

Develop a training session with examples utilizing PowerPoint inclusive of the reimbursement methodologies mentioned above. Include in your training of the student any relevant teaching points as well as how you intend to evaluate the student's knowledge.

Please Provide a reference sourece

Answer 1

Accountable care organization (ACO) is referred to as a group of health care providers who agree to share responsibility for excellence, expenditure and management of care which indeed are linked with incentives for a definite population of patients. Thus in value-based payment it is very significant and crucial to identify and acknowledge the elements of an ACO.

Primary care is the foundation of a flourishing ACO that makes use of transparent performance measures to attain the basic objective of improving people health, patients’ experience of care, lessening the care expenses and improving the work life of health care providers. Thus the most significant benefit that ACO could bring for the healthcare business is to aim significantly towards cost savings.

Centers for Medicare & Medicaid Services (CMS) established the Medicare Shared Savings Program with an objective that ACO should adhere to the quality performance benchmarks and lessen Medicare expenditure by a significant portion in order to enable them to qualify to take part in the sharing of these cost savings.

Fee-for-service (FFS) is referred to as a payment model where services are unbundled and are paid for separately. Thus in health care it provides an incentive for physicians to provide more treatments because compensation to a great extent is dependent on the quantity of care.

However indication of the effectiveness of pay-for-performance in improving health care quality is varied without convincing and decisive proof that these programs can either succeed or fail. Furthermore patients are safeguarded from paying as cost-sharing is done by health insurance coverage thus they welcome any medical service that can assist and promote good health.

In US FFS is regarded as the most dominant physician payment method however it elevate expenses and dampens the effectiveness of integrated care. Furthermore a variety of reform efforts were endeavored, suggested or instigated to lessen its persuasion and manipulation towards bundled payments and capitation.

In capitation physicians are not provided with incentives to perform the necessary procedures as they are they are not paid anything additional for performing them. However in the Japanese health care system FFS is combined with a countrywide price setting instrument which facilitates to effectively manage expenses.

Episode-of-care is referred to as a reimbursement methodology which are indeed adapted to provide it to the health care providers such as hospitals and physicians which are normally based on a prediction towards expected expenses for providing the clinical health care services.

Thus it has been portrayed as a middle ground between fee-for-service reimbursement in which providers are paid for each service rendered to a patient and capitation in which providers are paid a lump sum per patient regardless of how many services the patient receives provided the risk is shared between payer and provider.

Furthermore in US bundled payments had been planned in the health care reform debate as a policy to lessen the health care expenditures. However commercial payers had also enumerated their concern and significance of bundled payments enabling to reduce expenses. In 2012 it was anticipated that just about one-third of US healthcare reimbursement exercise bundled methodology.