MHA FPX 5006 Assessment 1 Financial Basics

Finance is not the same with managing money since it involves other activities such as investing, borrowing, lending, planning for the future, saving and even guessing. There are mainly three categories of finance namely; individual finance, business finance and community/government finance (Nguyen & Trivedi, 2021). According to the US MHA FPX 5006 Assessment 1 Financial Literacy and Education Commission, there are five ways in which one can get information on money. Make money. In this case, one should understand his or her pay and how best to utilize it (Yuan, 2022)

Purpose of Health Care Reimbursement

Health insurance is not an instrument to purchase medical services. Rather, it offer workers cash to cover their medical expenses, even the part that has been covered by insurance. The base rate that CMS (Centers for Medicare & Medicaid Services) wants each school to be paid has been determined. The base fee depends on the status of the hospital (teaching, research, or community), its location, the number of patients it attends to, the cost of living in the area, and the types of services offered. Often, your health insurance or an administrative payer will pay for the service or a portion of it (Nguyen & Trivedi, 2021). In this case, healthcare groups can be described by the four Cs; costs, cash, capital, and control in terms of making profits. Thus, all the healthcare businesses need to have a look at their expenditures and seek to streamline them to make money (Adamson et al., 2019).

To be eligible for repayment, the following conditions must be met:To be eligible for repayment, the following conditions must be met. The applicant has to be eligible for the Medicaid as on the date of service. MHA FPX 5006 Assessment 1 Concerning the bills, these have to be for services that were received through the original MEC receipt or MEC restart that occurred at or after the date that Medicaid commenced. When such an person undergoes MEC for some time, stops it, then reapplies and qualifies for a specific Medicaid program, the MEC is switched on. Usually, it takes one year to be certified, and this is the most common procedure.

The applicant has not been paid in full by a third party or got any reimbursement from the Medicaid provider. • The medical bills must be for services, which include supplies or treatments received and that were eligible for Medicaid at the time of service. The applicant must present a proof of payment from the Medicaid. The enrollee cannot get a refund for bills that have been fully paid for by a third party such as Medicare, an insurance company, a charity, a family member or a friend unless the enrollee still owes the said third party. It is necessary to check that the enrollee is still liable for any actions being taken (Nguyen & Trivedi, 2021)

Medicare

Medicare is often available to people aged 65 and up. You might be able to get Medicare faster if you are crippled, have end-stage kidney disease, or ALS (also known as Lou Gehrig’s disease) (Adamson et al., 2019).

Managed Care

MHA FPX 5006 Assessment 1 Exclusive Provider Organization (EPO): this is a type of managed care in which the patient is required to pay the insurance company only if he/she seeks the services of doctors, hospitals, dialysis centers or other healthcare givers in the network. Usually out of network care is not paid, unless it is an emergency. If you want to be covered by an HMO, it is advisable to be based or work within the facility area. Sometimes, HMOs provide integrated care that is based on health and prevention as well as preparations for the future. Point of Service (POS): a system in which costs are reduced by going to hospitals, doctors and other net healthcare providers. For POS plans, one requires a referral from a primary care physician before one can visit a specialist. Without being mentioned and for a certain additional charge, one could get a connection with the medical personnel, structure, and provision that are not available online. (Counts et al., 2020).

Analysis of Reimbursement Process

This means that the payment analysis offers you a clear outlook on the payment situation which is very crucial if you want to ensure that your practice is in a position to introduce new treatment options.

 All medical facility services and births are covered by Medicare and the rates for the payment are determined by the CMS. A provider cannot seek an additional amount for the copay differential between the provider’s usual charges and Medicare’s allowable amounts. Part A and Part B facilities receive the most funding from Medicare (Nguyen & Trivedi, 2021).

 The second part of Medicare is named Medical Part B, it covers services of doctors, Outpatient services, and Centers for Health Maintenance. There are some doctors who are not included in the Medicare and they do not make a claim to Medicare instead they ask you to pay them directly. Bear in mind that before you select a doctor, ensure that the doctor accepts the medicare assignment. The non-participating companies may at times request that you pay some amount of money before you can make your claim. Generally, Medicare is limited to care received within the United States; it doesn’t cover care received in other countries unless it is an emergency and there is no doctor or hospital that accepts Medicare assignments nearby (Nguyen & Trivedi, 2021).

Medicare Advantage Plan

MHA FPX 5006 Assessment 1 Medicare Advantage plan commonly referred to as Part C is a little different because it is actually offered by private companies. Many organizations have a way of providing bills for services that are offered. I dislike it when you do not request Medicare to cover the unpaid charges as Medicare Advantage is a business model. If you were directly charged for covered costs, then you will be required to file a claim to your private insurance company in a bid to be reimbursed (Nguyen & Trivedi, 2021).

 Medicare Part D or prescription drugs are provided through the private insurance companies. Every plan has its own set of medications that are included in the plan’s coverage. These are the rules or lists referred to by the term ‘formulary’ and the prices are based on a tier system where for instance, you have generic, name, specialty, etc. The pharmacy that you choose to have your scripts filled whether it is a store or a mail order service will forward the requests for the approved drugs. You still have to pay for the copayment as well as the share that is required. According to Counts et al. (2020), you cannot file a claim to Medicare if you paid for the drug yourself.

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Thus, eighty percent of all your costs are covered by Medicare. These include the amounts which you have to pay when seeking services under original Medicare known as deductibles, copayments, and coinsurance. Others acquire additional insurance coverage under their own plans and this is known as Medigap to assist in the payment of the 20%. The ten plans are available, and each of them includes the coverage of different things. It will only cover the things that Medicare has agreed to cover (Nguyen & Trivedi, 2021).

 Some people may not know what Medicaid entails, where the money is obtained from, or how it is of advantage to each individual. These fees could be different than what doctors charge for patients who have private insurance or those who have chosen not to be insured. At times, the providers may request for what is known as ‘enhanced’ MA rates which are rates that are higher than usual. This depends on elements like the FMAP rate and other essential benchmarks (Giardino & De Jesus, 2020).

 There is what is referred to as the FMAP through which the federal government sends a certain amount of the costs to the states every year. MHA FPX 5006 Assessment 1 FMAP rates vary from one state to the other due to factors such as the per capita income of the state. The government share is normally at 57% and it may be as high as 75% for the low-income per capita states and as low as 50% for the high-income per capita states (Nguyen & Trivedi, 2021). The ratios of state government funding increase as per capita income decreases. In states such as New York, New Jersey, and Connecticut, the minimum FMAP rate is 50 percent. In Mississippi, nonetheless, it is a shocking 75% according to Namburi and Tadi (2020). Mississippi, on the other hand, can impact almost $3 for every $1 that the state spends on Medicaid. Overall, it can be said that providers in states with higher FMAP rates may likely receive more payment (Nguyen & Trivedi, 2021).

 Sometimes, the FMAP method fails to work in certain situations. MHA FPX 5006 Assessment 1 ACA increased FMAP rates for services for those who did not enroll for Medicaid before and whose income was below 138% of the federal poverty level in 2014 (Namburi & Tadi, 2020). This indicates that the federal government will cover all the costs for your treatment if you are newly eligible; however, from the year 2020, it will reduce to 90% (Giardino & De Jesus, 2020). New York, New Jersey and their providers are particularly interested in this deal because the higher rate will not vary according to per capita income as the old FMAP does.

MHA FPX 5006 Assessment 1 Managed Care                                                                                                              

The differences can be noticed when one looks at the payment for managed care deals and the fee-for-service payback methods. It is common for many doctors to charge their patients based on the services that they offer, but managed care contracts may employ VBP that is related to health outcomes. This is quite crucial for the providers who are changing from the fee-for-service model. Managed care in the health care delivery system aims at offering quality services while at the same controlling the costs. A managed care organization and a health care provider such as a physician can do this effectively by associating payment with operation, quality, and health outcome whilst at the same time ensuring that everyone in the managed care system receives equal care (Gilstrap et al., 2019).

MHA FPX 5006 Assessment 1 mechanism of payment may vary with the type of managed care group that is in place. The four most common types of MCOs in the modern health care system are the HMOs, the PPOs, the POS, and the MMA; Below, the HMO and PPO describe how payment differs in the two structures. A PPO may allow a provider to receive payment through a fee for service at a discounted rate whereas an HMO managed care arrangement would often pay the provider per enrolled member per month. FFS payment models are not new, but the use of vbm such as capitation is growing. Performance-oriented remunerations, which reward MCOs based on health results, have helped MCOs to understand and manage costs of health care (Gilstrap et al., 2019).