Reimbursement In The Health Care Sector

Reimbursement In The Health Care Sector


The finance department is sensitive in all the sectors of the economy. In the health care sector of the USA, the service providers are regulated by regulations from the state and the federal government. The CMS controls and governs the firms in this industry (Casto & Forrestal, 2013). Financing in this sector is challenging and often requires the introduction of third-party payers to help streamline the flow of resources. To ensure financial sustainability, the health care providers rely on the third party, patients, and the CMS (Forsberg, Axelsson,& Arnetz 2017). Full reimbursement in time helps to ensure efficiency in the performance of firms in the health care industry.

Achievement of full reimbursement often requires the firms in the industry to follow a set of guidelines set by the authorities responsible for compensation. As well, the firms have to act in line with a set of financial principles and strategies that make them liable for reimbursement.

Part 1: Financial Principles and Reimbursement

Reimbursement Strategies

Case rates often are used for infectious disease, and imply the number of cases of the contagious illness over a while as a factor of the population during that period, mostly a population of 100,000 people (Forsberg, Axelsson & Arnetz, 2017). On the other hand, utilization management entails a set of systems that are utilized by or on behalf of procurers of health care benefits to manage health care overheads by impelling patient care decisions. These two concepts are essential in coming up with decisions that are of importance to disease control in the health care sector.

Case rates are of importance in raising the pay for performance incentives to the health care workers. The health care industry often has to face off with infectious diseases and ensure a stop in their spread. During outbreaks, the authorities look at the severity of the disease and give them incentives to professionals in the health care industry to help motivate in their work.

Utilization management similarly integrates prospective, retrospective, and concurrent measures to help determine the pay for performance incentives. It is tied to financial policies that ensure regulations, quality, and risks are risks that are assessed to support the management to take the appropriate course of action. Utilization management thus provides a substantial effect on the determination of the incentives to be awarded to the health workers.




Reimbursement Methods

Reimbursement Method Advantages

For Strategic Planning of Operational Performance


For Strategic Planning of Operational Performance

Best Use

(Type of Facility and Why)

Accountable care organization This model helps to provide an unconventional source of income to the health care industry while delivering the required structures and information systems The model is highly risky to the industry thereby making the doctors mechanical in their work This method can be of considerable significance to the public health care sector due to its stringent pressure on the delivery by the health care professionals
Prometheus payment It gives physicians bonuses for doing their work efficiently without attaching financial risks to the bonuses The model does not provide the required infrastructure to make the model work This model can be best used in the private health care sector, where the resources may not be efficient in providing the necessary infrastructure. Through the model, the professionals in this would use the available support to gain optimal results


Financial Management Principles


Financial Management Principle How It Is Used to Evaluate Operational Performance
Strategy formulation This principle necessitates the formulation of strategies in carrying out tasks. The employees are then appraised based on their ability to meet the set objectives
Execution of the strategy This principle enables appraisal of the employees based on their results and the time taken to achieve such results
Accountability It appraises employees based on their accountability to the results gained.


Accounts Receivable

Accounts receivables in the health care sector mostly are from payments by the patients. The industry, however, faces challenges during the collection of such payments. Some of the most prominent challenges include the denial of insurance and bad debts. These challenges harm the revenue received by the industry.

Denials of insurance claims contribute mainly to the losses made by the industry. These arise when insurance companies fail to clear up medical bills by denying their cover of the patients in question. Bad debts, on the other hand, arise from failure by the patients to make their payments upon receipt of treatment.

The firms in the health care sector must regularly evaluate their cash flows and days in accounts receivable. Such measures help in planning as they provide the information on the amount of time payment may be due. Monitoring also helps to eliminate errors that may have arisen throughout the process.



Teamwork Principles

Teamwork Principle Used with Cross-Disciplinary Teams A Challenge Presented By This Principle and Why
Leadership and management This principle poses the challenge of identification of the best leader from the group which may be hard
Proper communication Gaining coherence involves the connection from the individual level to the group level thus may be hard to achieve due to personality differences
Team climate The team members relationship may be hard to control due to their differences in opinions
Clarity of vision This principle is challenging in the sense that it is not easy to ascertain what is evident.


Maximizing Reimbursement

The management of the health care sector often reimburses their payers. There is the use of case rate and utilization management in the maximization of such repayments  To achieve maximum reimbursement. However, the refunds are not often only determined by these factors but by other factors too.

The reimbursement decision-making process would lead to a decision on how to reimburse. Transparent processes often earn maximum reimbursement. Moreover, the reimbursement process is also affected by patient cost-sharing. Patient cost-sharing limit the effects of innovation in the industry and thus jeopardize the maximization process.

Part 2: Federal and State Payment Systems

Federal and State Regulations

The Patient Protection and Affordable Care Act (ACA) of 2010. The ACA regulation set by the State government to ensure increased access to health care, promote quality, and to improve efficiency. It offers stakeholders opportunities and as well presents challenges to the sector.

Accountable Care Organizations act of 2011. This law enhances the ability of the pharmacies to manage and expand the scope of their activities.

The management in the health care system needs to take a keen look at the regulations as they give the guidelines for which operations are to be carried out. Failure to carry out activities by law may lead to legal problems.

Reporting Requirements

            The CMS gov abbreviates Centers for Medicare & Medicaid Services and involves a federal agency in the USA Department of Health and Human Services that administers Medicare programs and works.

The CMS requires reports on the MSP input file, which contains the GHP covered individuals satisfying the criteria of Active Covered Individual. As well, the CMS requires the news on the Non-MSP input file, which entails a list of the prescription drug insurance coverage information for the Inactive covered individuals.

The CMS has added advantage to the health care industry through decreased costs, provision of accredited care, cheaper prescriptions, and availability of extensive in-network providers. However, reporting on the CMS also bears challenges. These challenges include strict approval processes, inability to refer, and lack of specialty in treatment.

Compliance Standards

            In ensuring compliance with the CMS guidelines, the health care facility should put into consideration the financial management principles. The principles help to blend and streamline the organization. These principles include accountability and strategy.

Accountability is an integral part of any institution. All the processes should be done in an accountable manner. Responsibility would ensure reimbursement from the CMS is done on time. Also, strategy as a principle is essential for the growth of any organization. To access the CMS, the facility must have policies that are compliant with the CMS regulations.

Government Payer Types

Reimbursement by the CMS requires proper clarity in the activities of the health care facility. There should be no doubt in the processes to get the full rebate. To achieve total compensation, the facility may need to put into place strategies that ensure clarity, for instance, the policy of accountability and transparency of vision.

The processes in the facility should be accounted for entirely. Often financial records have to be checked to ascertain the errors in them. Such accountability enables trust in the system, thus fastening and ensuring full reimbursement. Moreover, facilities need to have more lucid visions in line with the CMS regulations to get their total compensation.



Part 3: Third-Party Payment Systems

Healthcare System Reimbursement

A third-party payer is an entity other than the patient or the healthcare provider that reimburses health care expenses. One of the biggest third-party payers in the US is the Blue Cross. These institutions are essential in the recovery of health care expenses.

The third-party payers are essential in settling the risk of bad debts. The third parties help to resolve the medical bills in case the patients fail to pay them (Henkel & Maryland, 2015). The third parties help to prevent the risk of denial by the insurance companies as they step in to fill such gaps. It is, therefore, evident that the third-party payers have a role to play in the development of the health care sector. Due to such benefits carried by the third-party payers, the health service providers should meet their requirements.


Reporting Requirements


The blue cross is a third party pare in the USA. This payer requires reports to facilitate reimbursement claims. Such statements include the data of the individual patients in question and the health records of such patients. The third-party payers are essential to the health care sector in the sense that they offset the possibility of losses. On the other hand, the payers may be disadvantageous in the fact that they require constant adequate reporting of the entire process.



Compliance Standards

            Third-party payers require compliance with set guidelines and procedures in their reimbursement process. Failure to comply with standards leads to delayed reimbursement or even no reimbursements. To ensure such an agreement, health care providers must comply with the financial principles of accountability and strategy.

The service providers must ensure that all the accounting processes in their books are accountable. There should be no questioning of the operations. Additionally, they should ensure that they have the stack to the organization’s strategy to avoid miss expenditure as such may not warrant a reimbursement.

Reimbursement Methods

            To be reimbursed by third-party payers, the health care service providers should ensure the accountability and clarity of their operations. Acting on transparency will ensure the reimbursements are earliest and fully paid.

Part 4: Operational and Strategic Planning in Healthcare

Pay-For-Performance Incentives

            I would recommend that the organization reassess the current state of affairs. There is a need to re-look at the process in totality To gain a full reimbursement. Reassessing the process will help identify the areas that are not done correctly.

The organization as well would need to understand the reimbursement cycle. The cycle is essential in gaining full and timely reimbursement. This understanding aids to know what is required and the point of its requirement.

Operational Performance Measures

In the health care sector, there are several performance measures—these measures highlight which facilities are performing well and those that are not performing well. In gaining full reimbursement, I would recommend the adoption of performance measures as the retention of patients and the readmission rates of the patients (Kavanagh, Cimiotti, Abusalem & Coty, 2018). These two measures would help the organization to move to greater heights, therefore, gain a full reimbursement.

Teamwork and Strategic Planning

Collaborative Teamwork Technique How It Will Help Maximize Reimbursement
Proper communication Communication helps avail required information to the third-party payers impartially thus maximizing reimbursement
Encouraged innovation Innovation leads to improvements in techniques and processes which improve performance, thus maximizing reimbursements.


Communicating Strategic Planning Across Teams

            Communication is essential in all parts of the health care industry. To ensure efficiency and consistency in the flow of information, I would recommend verbal and written methods of communication. Through such means, data can reach all the stakeholders of the organization.


Financial and Reimbursement Strategies

++++++++++++ Cash Flow Days in Accounts Receivable
Recommendation for Low Performing System Track down the account receivables Consider an early payment discount for the clients
Recommendation for High Performing System Maintain clear and concise invoices Consider offering a payment plan



Casto, A. B., & Forrestal, E. (2013). Principles of healthcare reimbursement. American Health Information Management Association.

Forsberg, E., Axelsson, R., & Arnetz, B. (2017). Effects of performance-based reimbursement in healthcare. Scandinavian journal of public health, 28(2), 102-110.

Henkel, R. J., & Maryland, P. A. (2015). The risks and rewards of value-based reimbursement. Frontiers of health services management, 32(2), 3-16.

Kavanagh, K. T., Cimiotti, J. P., Abusalem, S., & Coty, M. B. (2018). Moving healthcare quality forward with nursing‐sensitive value‐based purchasing. Journal of Nursing Scholarship, 44(4), 385-395.

Get professional assignment help cheaply

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason may is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Our essay writers are graduates with diplomas, bachelor, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college diploma. When assigning your order, we match the paper subject with the area of specialization of the writer.

Why choose our academic writing service?

  • Plagiarism free papers
  • Timely delivery
  • Any deadline
  • Skilled, Experienced Native English Writers
  • Subject-relevant academic writer
  • Adherence to paper instructions
  • Ability to tackle bulk assignments
  • Reasonable prices
  • 24/7 Customer Support
  • Get superb grades consistently





Get Professional Assignment Help Cheaply

Buy Custom Essay

Are you busy and do not have time to handle your assignment? Are you scared that your paper will not make the grade? Do you have responsibilities that may hinder you from turning in your assignment on time? Are you tired and can barely handle your assignment? Are your grades inconsistent?

Whichever your reason is, it is valid! You can get professional academic help from our service at affordable rates. We have a team of professional academic writers who can handle all your assignments.

Why Choose Our Academic Writing Service?

  • Plagiarism free papers
  • Timely delivery
  • Any deadline
  • Skilled, Experienced Native English Writers
  • Subject-relevant academic writer
  • Adherence to paper instructions
  • Ability to tackle bulk assignments
  • Reasonable prices
  • 24/7 Customer Support
  • Get superb grades consistently

Online Academic Help With Different Subjects


Students barely have time to read. We got you! Have your literature essay or book review written without having the hassle of reading the book. You can get your literature paper custom-written for you by our literature specialists.


Do you struggle with finance? No need to torture yourself if finance is not your cup of tea. You can order your finance paper from our academic writing service and get 100% original work from competent finance experts.

Computer science

Computer science is a tough subject. Fortunately, our computer science experts are up to the match. No need to stress and have sleepless nights. Our academic writers will tackle all your computer science assignments and deliver them on time. Let us handle all your python, java, ruby, JavaScript, php , C+ assignments!


While psychology may be an interesting subject, you may lack sufficient time to handle your assignments. Don’t despair; by using our academic writing service, you can be assured of perfect grades. Moreover, your grades will be consistent.


Engineering is quite a demanding subject. Students face a lot of pressure and barely have enough time to do what they love to do. Our academic writing service got you covered! Our engineering specialists follow the paper instructions and ensure timely delivery of the paper.


In the nursing course, you may have difficulties with literature reviews, annotated bibliographies, critical essays, and other assignments. Our nursing assignment writers will offer you professional nursing paper help at low prices.


Truth be told, sociology papers can be quite exhausting. Our academic writing service relieves you of fatigue, pressure, and stress. You can relax and have peace of mind as our academic writers handle your sociology assignment.


We take pride in having some of the best business writers in the industry. Our business writers have a lot of experience in the field. They are reliable, and you can be assured of a high-grade paper. They are able to handle business papers of any subject, length, deadline, and difficulty!


We boast of having some of the most experienced statistics experts in the industry. Our statistics experts have diverse skills, expertise, and knowledge to handle any kind of assignment. They have access to all kinds of software to get your assignment done.


Writing a law essay may prove to be an insurmountable obstacle, especially when you need to know the peculiarities of the legislative framework. Take advantage of our top-notch law specialists and get superb grades and 100% satisfaction.

What discipline/subjects do you deal in?

We have highlighted some of the most popular subjects we handle above. Those are just a tip of the iceberg. We deal in all academic disciplines since our writers are as diverse. They have been drawn from across all disciplines, and orders are assigned to those writers believed to be the best in the field. In a nutshell, there is no task we cannot handle; all you need to do is place your order with us. As long as your instructions are clear, just trust we shall deliver irrespective of the discipline.

Are your writers competent enough to handle my paper?

Our essay writers are graduates with bachelor's, masters, Ph.D., and doctorate degrees in various subjects. The minimum requirement to be an essay writer with our essay writing service is to have a college degree. All our academic writers have a minimum of two years of academic writing. We have a stringent recruitment process to ensure that we get only the most competent essay writers in the industry. We also ensure that the writers are handsomely compensated for their value. The majority of our writers are native English speakers. As such, the fluency of language and grammar is impeccable.

What if I don’t like the paper?

There is a very low likelihood that you won’t like the paper.

Reasons being:

  • When assigning your order, we match the paper’s discipline with the writer’s field/specialization. Since all our writers are graduates, we match the paper’s subject with the field the writer studied. For instance, if it’s a nursing paper, only a nursing graduate and writer will handle it. Furthermore, all our writers have academic writing experience and top-notch research skills.
  • We have a quality assurance that reviews the paper before it gets to you. As such, we ensure that you get a paper that meets the required standard and will most definitely make the grade.

In the event that you don’t like your paper:

  • The writer will revise the paper up to your pleasing. You have unlimited revisions. You simply need to highlight what specifically you don’t like about the paper, and the writer will make the amendments. The paper will be revised until you are satisfied. Revisions are free of charge
  • We will have a different writer write the paper from scratch.
  • Last resort, if the above does not work, we will refund your money.

Will the professor find out I didn’t write the paper myself?

Not at all. All papers are written from scratch. There is no way your tutor or instructor will realize that you did not write the paper yourself. In fact, we recommend using our assignment help services for consistent results.

What if the paper is plagiarized?

We check all papers for plagiarism before we submit them. We use powerful plagiarism checking software such as SafeAssign, LopesWrite, and Turnitin. We also upload the plagiarism report so that you can review it. We understand that plagiarism is academic suicide. We would not take the risk of submitting plagiarized work and jeopardize your academic journey. Furthermore, we do not sell or use prewritten papers, and each paper is written from scratch.

When will I get my paper?

You determine when you get the paper by setting the deadline when placing the order. All papers are delivered within the deadline. We are well aware that we operate in a time-sensitive industry. As such, we have laid out strategies to ensure that the client receives the paper on time and they never miss the deadline. We understand that papers that are submitted late have some points deducted. We do not want you to miss any points due to late submission. We work on beating deadlines by huge margins in order to ensure that you have ample time to review the paper before you submit it.

Will anyone find out that I used your services?

We have a privacy and confidentiality policy that guides our work. We NEVER share any customer information with third parties. Noone will ever know that you used our assignment help services. It’s only between you and us. We are bound by our policies to protect the customer’s identity and information. All your information, such as your names, phone number, email, order information, and so on, are protected. We have robust security systems that ensure that your data is protected. Hacking our systems is close to impossible, and it has never happened.

How our Assignment  Help Service Works

1.      Place an order

You fill all the paper instructions in the order form. Make sure you include all the helpful materials so that our academic writers can deliver the perfect paper. It will also help to eliminate unnecessary revisions.

2.      Pay for the order

Proceed to pay for the paper so that it can be assigned to one of our expert academic writers. The paper subject is matched with the writer’s area of specialization.

3.      Track the progress

You communicate with the writer and know about the progress of the paper. The client can ask the writer for drafts of the paper. The client can upload extra material and include additional instructions from the lecturer. Receive a paper.

4.      Download the paper

The paper is sent to your email and uploaded to your personal account. You also get a plagiarism report attached to your paper.

smile and order essaysmile and order essay PLACE THIS ORDER OR A SIMILAR ORDER WITH US TODAY AND GET A PERFECT SCORE!!!

order custom essay paper