Introduction
Healthcare reimbursement plays a crucial role in ensuring the continuous delivery of quality services in the healthcare system. According to Torrey (2020), healthcare reimbursement refers to a patient’s payment to their healthcare providers after receiving care. In many instances, a person’s medical bill is often covered by the health insurer of a government payer.
However, depending on an individual’s health plan, they may be responsible for some percentage of the cost, and if they lack healthcare coverage, they may be required to reimburse their healthcare provider fully. While healthcare reimbursement is an essential part of the continuous delivery of quality care, it also faces issues affecting providers and payers. This paper discusses healthcare reimbursement issues and the challenges of healthcare reimbursement concepts.
Healthcare Reimbursement Issues
The Medicare prospective payment system (PPS) is the first healthcare reimbursement issue. According to Chapter 7, the US Congress created PPS in 1982 to “monitor the overall use of hospital resources while simultaneously monitoring the quality and care delivered to the patient” (P. 118). Generally, PPS was meant to help reduce the cost of health care. However, although PPS has proven effective over the years, determining reimbursement rates that align with providers’ actual cost of services has been challenging (Davis & Kan, 2019). As a result, healthcare providers are underpaid for their quality services.
The second healthcare reimbursement issue is transitioning to a value-based care model, such as bundled or episode-of-care payments. Today, many countries are implementing strategies in their healthcare sectors to focus more on the quality of care that providers offer patients (Teisberg et al., 2020). While this is an improvement in the healthcare sector, it is a reimbursement issue. This transition affects the measurement of patient outcomes and fairly reimbursing providers for their quality services (Chapter 7). Therefore, nations must develop and implement other standardized quality metrics to assess patient outcomes, requiring more input.
Challenges of Healthcare Reimbursement Concepts
The first challenge of healthcare reimbursement concepts is inadequacy. For many years, the healthcare system has failed to offer healthcare providers adequate reimbursement for their service to patients (Chapter 7). Barouni et al. (2020) note that the PPS’s stipulated fixed payments sometimes fail to align with patient care resources. As a result, many healthcare providers feel less valued and appreciated due to underpayment. Such healthcare providers cannot offer patients quality care, affecting healthcare operations. Hence, PPS affects the quality of care offered in healthcare organizations.
Another difficulty in relation to healthcare reimbursement concepts is the constant changes in policies and regulations. People often find keeping up difficult when changes are frequently introduced in any setting. While some may take time and finally adapt, others fail. According to Figueroa et al. (2019), the frequent policy and regulatory challenges in healthcare reimbursement make it challenging for many organizations and providers to accommodate, affecting care delivery. This may compel the government and healthcare providers to invest additional resources and personnel to help adjust.
Billing and Coding Regulations
In healthcare organizations, billing and coding regulations help determine the correct reimbursement. One billing and coding regulation is the Medicare and Medicaid Billing Regulations, which govern the rate of reimbursement and documentation (Burks et al., 2022). Unlike Medicare and Medicaid Billing Regulations, the Healthcare Common Procedure Coding System (HCPCS) guides organizations in coding procedures, services, and supplies (Burks et al., 2022).
Another regulation is the insurance payer guidelines for private insurance payers. These guidelines significantly vary from Medicare and Medicaid (Burks et al., 2022). Even though these regulations are different, they all help control the reimbursement rates.
Conclusion
In conclusion, healthcare reimbursement plays a significant role in ensuring consistent delivery of quality care and improvement of patient outcomes. However, it has grown to be a complex area that experiences many issues and challenges. Healthcare providers and payers must work together to identify and address these issues to enhance the system’s effectiveness. Without intervening, both healthcare providers and payers stand a chance of being affected.
References
Barouni, M., Ahmadian, L., Anari, H. S., & Mohsenbeigi, E. (2020). Challenges and adverse outcomes of implementing reimbursement mechanisms based on the diagnosis-related group classification system: A systematic review. Sultan Qaboos University Medical Journal, 20(3), e260-e270. Web.
Burks, K., Shields, J., Evans, J., Plumley, J., Gerlach, J., & Flesher, A. S. (2022). A systematic review of outpatient billing practices. SAGE Open Medicine, 22(3). Web.
Chapter 7. (n.d.). Medicare prospective payment systems. In CY 2022, Acute Care Prospective Payment System.
Davis, M. M., & Kan, K. (2019). Adjusting hospital reimbursement to account for social influences on health. JAMA Network Open, 2(9), e1913630-e1913630. Web.
Figueroa, C. A., Harrison, R., Chauhan, A., & Meyer, L. (2019). Priorities and challenges for health leadership and workforce management globally: A rapid review. BMC Health Services Research, 19(1), 1-11. Web.
Teisberg, E., Wallace, S., & O’Hara, A. S. (2020). Defining and implementing value-based health care: A strategic framework. Academic Medicine, 95(5), 682. Web.
Torrey, T. (2020). Understanding healthcare reimbursement. Verywell Health. Web.