Order Instructions
Assessment Traits
Requires Lopeswrite
Assessment Description
The purpose of this assignment is to discuss how different insurance providers reimburse health care organizations for services.
You are the nursing administrator at a community hospital providing a training for your unit directors.
Create a 12- to 14-slide PowerPoint Presentation (excluding the title and reference slides) addressing the following:
Discuss how Medicare, Medicaid, and private insurance reimburse health care organizations.
Describe the differences between cost, charge, and payment.
Explain Diagnostic Related Groups (DRGs) and provide at least two examples.
Discuss how insurance reimbursement affects private pay patients (those with no insurance).
Include at least 3 peer-reviewed resources.
Additionally, include a title side, reference slide, comprehensive speaker’s notes, and graphics that are relevant to the content, visually appealing, and placed appropriately.
Refer to the resource, “Creating Effective PowerPoint Presentations,” located in the Student Success Center, for additional guidance on completing this assignment in the appropriate style.
While APA style is not required for the body of this assignment, solid academic writing is expected, and documentation of sources should be presented using APA formatting guidelines, which can be found in the APA Style Guide, located in the Student Success Center.
This assignment uses a rubric. Please review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Class Resources if you need assistance.
SAMPLE ANSWER
Medicare, Medicaid, and private insurance are three of the most common ways that healthcare organizations are reimbursed for the services they provide. Each method has its own set of guidelines and procedures that healthcare organizations must follow to receive reimbursement.
Medicare is a federal health insurance program for individuals who are 65 years of age or older, younger people with disabilities, and people with end-stage renal disease. Medicare reimburses healthcare organizations using a fee-for-service model, where providers are paid based on the services they provide. The amount reimbursed is determined by the Medicare fee schedule, which outlines the maximum amount that Medicare will pay for each service. Medicare also uses a prospective payment system (PPS) for certain types of services, such as inpatient hospital stays, where the payment is fixed and based on the diagnosis-related group (DRG) assigned to the patient.
Medicaid is a joint federal-state program that provides health insurance to low-income individuals and families. Medicaid reimburses healthcare organizations using a combination of fee-for-service and managed care models. In fee-for-service, providers are paid for each service they provide, while in managed care, providers are paid a fixed amount per patient per month.
Private insurance is health insurance that is purchased by individuals or provided by employers. Private insurance reimburses healthcare organizations using a variety of models, including fee-for-service, capitation, and bundled payments. In fee-for-service, providers are paid for each service they provide, while in capitation, providers are paid a fixed amount per patient per month, regardless of the services provided. In bundled payments, providers are paid a single amount for all services related to a specific procedure or episode of care.
Cost, charge, and payment are three terms used to describe the financial aspects of healthcare reimbursement. Cost refers to the actual cost of providing a service, including the cost of labor, supplies, and equipment. Charge refers to the amount that a healthcare organization bills for a service. Payment refers to the amount that a healthcare organization actually receives for a service.
Diagnostic Related Groups (DRGs) are a system used by Medicare to reimburse healthcare organizations for inpatient hospital stays. DRGs group patients with similar diagnoses and medical conditions together and assign a fixed payment amount for each group. This system is designed to encourage healthcare organizations to provide efficient and effective care. Two examples of DRGs are:
DRG 291 – Heart Failure and Shock with MCC: This DRG includes patients who have a primary diagnosis of heart failure or shock and have major complications or comorbidities.
DRG 470 – Major Joint Replacement or Reattachment of Lower Extremity with MCC: This DRG includes patients who have undergone major joint replacement or reattachment of the lower extremity and have major complications or comorbidities.
Insurance reimbursement can affect private pay patients in several ways. Healthcare organizations often charge higher rates for services to uninsured or self-pay patients to make up for the lower rates they receive from insurance companies. This can make healthcare services unaffordable for some patients. However, some healthcare organizations offer discounts or payment plans for uninsured or self-pay patients.
References:
Centers for Medicare & Medicaid Services. (2021). Medicare reimbursement basics. https://www.cms.gov/Medicare/Coordination-of-Benefits-and-Recovery/ProviderServices/Reimbursement-Basics
Medicaid.gov. (2021). Medicaid reimbursement. https://www.medicaid.gov/medicaid/financing-and-reimbursement/reimbursement/index.html
American Medical Association. (2021). Private payer reimbursement. https://www.ama-assn.org/practice-management/payment-delivery-models/private-payer-reimbursement
Centers for Medicare & Medicaid Services. (2021). Diagnosis-related groups (DRGs).