Experiential Learning Activity Discussion

Anonymous

Question Description

Part1 (discussion)

for our experiential learning activity discussion this week you will explore Payers and provide an analysis:

- Research and search the internet to find a payer
- Describe the payer, including the payer's covered patient market, type of payer, etc.
- Summarize one current event in the industry that may have a strategic impact on the payer

Please be sure to include and cite your reference sources following best writing practices.


Part2

**this what we have to do for Learning journal reflection: (usually see the topics in the book and paraphrase it or talk about it in two or three sentences)

complete your learning journal reflection by Thursday, June 20th.

Learning Journal Title: Chapter 7
Learning Journal Topics:

Payers and Payer Data

Claims and EDI

Model Process Step
Decision Tree Node
Decision Tree Model (vs. Linear/Logistic Regression)
Decision Tree Model Evaluation

Tutor Answer

fuhrmann
School: Boston College

Hello, please find the attached which is the final version of your work. Feel free to inform me in case of any clarification concerning the work. I am looking forward for a good review and working on your future projects. Thank You

Running head: DISCUSSION

1

Discussion
Student’s Name
Institutional Affiliation

DISCUSSION

2
Discussion

Part 1
Healthcare remains one of the most important sectors in the US economy since it
determines the productivity of a country’s labor force. However, with the rapid population
growth across the globe and in the US, the desire of every country to provide quality healthcare
services at affordable prices to their citizens remains elusive. Because of the high cost of
financing universal healthcare to every citizen, the government always allow other healthcare
organizations and insurance companies to take part in health care provisions, and encompasses of
key players like the payer, payer’s covered patient, and the healthcare provider. A payer refers to
any business organization that is involved in enrolling a patient for a healthcare cover, offering
healthcare plan, verifying the healthcare claims sent by the patient or the provider, and making
payments to the providers. A payer’s covered patient on the other hand refers to the person who
takes medical cover by paying regular premiums to the payer in order for the provider, which is
the hospital, to provide the necessary healthcare services in case the healthcare disease that is
covered occurs.
In the US, there are two major types of healthcare payers which are public and private
payers. The public payers are those that are financed and regulated by the government such as
the Medicare which covers individuals above 65 years, the Medicaid which comprises of both
the federal and state governments, and lastly the Tricare, which is regulated by the Department
of Defense and caters solely for servicemen and their families. Private payers on the other hand
are healthcare insurance organizations which enters into private contracts with patients and
provide medical covers to these patients privately. One current event in the healthcare industry
that may have a strategic impact on the payer was the introduction of the Affordable Care Act

DISCUSSION

3

which introduced the universal medical healthcare to all American citizens. With the
affordability of the “Obama Care” compared to the private medical covers, most Americans have
today shifted their loyalty from private payers to the public payers, thus impacting the healthcare
industry and composition of the payers.
Part 2
1. Payers and Payer Data
As discussed above, the payer is the organization that provide medical covers to patients. Payer
data are useful in assessing the subscription of medical covers by patients in the country. Until
the enactment of the Affordable Care Act, many Americans preferred private payer to public
payer. However, with the commitment of the federal government to promote universal healthcare
in the US, the payer data shows that there is an increasing number of people who are opting for
public medical covers.
2. Claims and EDI
Medical claims are the medical bills which the provider often submit to healthcare insurance
carriers, the payer, for various healthcare services rendered to patients by these providers. The
willingness of the payer to finance such medical claims submitted to them by the healthcare
providers often depend on whether the patient is covered by the services rendered. The
connection between the provider and the payer is always enhanced by the existence of the
electronic data interchange (EDI), which allows electronic communication between these two
parties.
3. Model Process Step
Some of the key steps involved in model process are; a...

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Review

Anonymous
Thanks, good work

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