Description
Scenario: Medicare and private payers have expanded reimbursement under Accountable care organizations (ACO). You are the chief financial officer (CFO) of a hospital system that is forming an ACO to participate in these payment models. The ACO seeks to improve care coordination for its patients with chronic conditions. To provide better care management, the ACO is interested in investing in primary care physicians and physician’s assistants to provide more intensive care management services. After formation, the ACO will enter contracts with Medicare and private insurers under alternative payment models, including shared savings, bundled payments, and global capitation. The ACO will need to determine how to set up reimbursement payments to ACO providers and consider whether financial incentives are required to ensure ACO providers deliver efficient care.
As the CFO of the ACO in the provided scenario, recommend strategies for reimbursement and utilization management. Defend your recommendations.
o How might you set up the reimbursement payments to ACO providers, considering the alternative payment models (i.e., fee for service, shared savings, bundled payments, or global capitations)?
o What utilization management controls might you add to align the interests of ACO providers?
References
Zelman, W. N., McCue, M. J., Glick, N. D., & Thomas, M. S. (2014). Financial management of health
care organizations: An introduction to fundamental tools, concepts and applications (4th ed.). San
Francisco, CA: JosseyBass.
McClellan, M. (2015). Accountable care organizations and evidencebased
payment reform. Journal of the American Medical Association, 313(21), 2128–2130.
Explanation & Answer
HEALTH AND MEDICARE
1
Reimbursement Strategies
Name
Instructor
Course Title
Date
HEALTH AND MEDICARE
2
Reimbursement strategies
The quest to lower health cost while maximizing on the quality has been a born of contention for
quite a long time, professionals over decades have tried to put to the table substantial models that
are intended to expand the health fraternity. Reimbursement strategies are simply new
technologies that are meant to steer health care into a new era moving from the old and
traditional way of fee for service. A number of models have been put forth to take care of acute
illness both for inpatient and outpatient while those who suffer from chronic illness have been
ignored.
Setting a reimbursement payment is critical for primary care physicians and physician assistant
in the provision of a comprehensive management care service, especially for patients with
chronic conditions. There are a number of payment modes that range from manual to software,
these include; intuit online payroll, QuickBooks online payroll and direct deposit reimbursement.
The best reimbursement payment mode in such a case is direct deposit reimbursement because it
does not require any validation process more so in dealing with patients with ch...
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