response 4-1 Discussion: Prospective Payment Systems and Reimbursement

RESPONSE TO THE FOLLOWING TWO POST SEPERATELY AND LABEL THEM JUST LIKE I HAVE THEM LABEL.. THIS IS NOT AN ESSAY BUT A RESPONSE AS IF YOU ARE LISTENING TO SOME ONE TALK AND THEN RESPONDING TO THAT PERSON. BE SURE TO ADDRESS EACH STUDENT BY THEIR NAME AND STATE IF YOU AGREE OR DISAGREE WITH THEIR POST.. THEY ARE TWO DIFFERENT POST ANSWER THEM SEPARATELYIn response to your peers, offer another potential impact on operations that prospective systems could have.POST 14-1 Discussion: Prospective Payment Systems and ReimbursementContains unread postsDaniella Davis posted Jul 22, 2020 5:00 PMUnder a prospective payment plan, a healthcare provider will always receive the same payment for providing the same specific type of treatment. Prospective payment plans have several benefits, for example, they tend to motivate providers to deliver the most efficient care possible. A disadvantage is providers receive the same payment regardless of the quality of care, some might be moved to offer less thorough and less personalized service. Prospective payment plans have the potential to save insurance companies money, and when that happens, some of those savings may be passed on to patients in the form of lower annual premiums and copayments. A non-prospective payment plan pays a doctor or other provider of healthcare on their actual charges. With a non-prospective payment plan, a provider will treat a patient and submit an itemized bill to an insurance company detailing the services rendered. The insurance company, in turn, may approve or deny payment for the treatment or portions of those treatments. Medicare, for example, will not pay in full, only the allowable amount, unless the patient has Medicare supplement plan F.The primary benefit of non-prospective payment plans is that the patients can receive more attention.Depending on the service, some payments are covered, for example, a transplant. Some hospitals must be approved for certain surgeries. A hospital will have to perform several surgeries of a certain type or disease state, for example, bariatric surgeries, to be approved. The patient wants to go to a hospital that accepts their insurance whether Medicare or commercial insurance.A patient may go to a hospital that is further from their home for any non-life-threatening or non-emergency issues if their insurance is not accepted at the hospital closest to their home. Accepting assignment from Medicare will not be as profitable, however, more revenue will be lost from patients going elsewhere for care.The doctors that do not accept Medicare assignment will bill the patient separately. Harrington, M. K. (2020). Health care finance and the mechanics of insurance andreimbursement. Jones & Bartlett Learning.POST 2Prospective Payment Systems and ReimbursementContains unread postsElizabeth Eng posted Jul 21, 2020 3:16 PMHello class,The two basic types of bundled payment models in healthcare are the retrospective payment system (RPS) and the prospective payment system (PPS). As the terms imply, the RPS provides reimbursement after services are rendered while the PPS promises a fixed amount for services before they are delivered (Watne, 2017). According to the RPS, payments are made to the organization throughout the year to balance the costs of providing care to Medicare beneficiaries. At the end of the year, the hospital’s costs are reconciled with the payments made throughout the year. The amount reimbursed under the RPS varies according to fees-for-service, or the number and type of services provided to the patient (Harrington, 2020). This model offers more flexibility to providers in the amount and type of services they can provide, especially in patient cases that are unpredictable. However, it may also encourage providers to deliver services that may be more costly and unnecessary, as evidenced by the rise in healthcare costs (Gruessner, 2017). In contrast, reimbursements under the PPS are fixed according to the projected costs of delivering necessary services to patients of specific disease and/or resource groups. Both inpatient and outpatient PPS use classifications to determine the number and type of services normally provided to a patient with a specific condition, such as type 2 diabetes with peripheral arterial disease. Inpatient encounters such as hospital admissions, rehabilitation, and long term care use Medicare severity diagnosis related groups (MS-DRG or DRG) or case-mix groups (CMG). Outpatient encounters for hospital services or home health care use ambulatory payment classifications (APC) and home health resource groups (HHRG). These reflect the clinical management and resource needs in caring for patients of similar diagnoses. Classifications are based on the ICD-10-CM and HCPCS coding systems and contain the codes applying to the patient’s diagnosis as well as procedures and supplies used (Harrington, 2020). All the anticipated costs of providing comprehensive treatment/therapy for these encounters are bundled into a single, fixed payment. This system is more heavily regulated than the RPS, but it encourages providers to improve care efficiency and manage the costs of care delivery more effectively. If care costs less than the payment amount, the organization keeps the difference. However, the organization bears the loss if the cost of care exceeds the payment (Watne, 2017). The PPS helps contain costs by encouraging providers to deliver only necessary services and to use lower-cost, but equally effective options when possible. It also helps enhance care efficiency, which often results in quality improvement. However, the strict regulations of this system can limit options in care delivery, especially for patients who do not fit neatly into specified classifications (Watne, 2017). The PPS also carries more financial risk for organizations since patient behaviors and side effects are often difficult to predict. Transferring risk to providers can be beneficial if it encourages them to “[deliver] a complete case for less than the negotiated price”; but it can be detrimental if it encourages providers to avoid patient cases that are by nature complicated and costly (Gruessner, 2017). Have a great week!Elizabeth EngReferencesGruessner, V. (2017, January 11). Prospective vs. retrospective healthcare bundled payment models. Health Payer Intelligence. https://healthpayerintelligence.com/news/prospective-vs.-retrospective-healthcare-bundled-payment-modelsHarrington, M. K. (2020). Health care finance and the mechanics of insurance and reimbursement (2nd ed.). Jones & Bartlett Learning. Watne, Z. (2017, May 24). Unraveling payment: Retrospective vs. prospective payment. Health University of Utah. https://accelerate.uofuhealth.utah.edu/connect/unraveling-payment-retrospective-vs-prospective-payment