Maximizing reimbursement essay



Howmanagers help maximize reimbursement

Inthe present day, the hospital has been facing a reduction in the poolof funds in healthcare as a result of inspection from Medicaid,Medicare and substantial penalties and business for abuse or scam.The growing trend is significant for the managers dealing with anemergency to screen the patient to ensure appropriateness ofadmission and that higher care level is granted to the patients. Thepatient must be allocated an appropriate care level irrespective ofwhether they are inpatient or outpatients. The managed care presentsan organized system that balances the costs, quality and access byintensive care management, utilization management and containment ofcosts (Powell,2000).

Themanagers serve an imperative role in ensuring that the hospital hasthe required patients occupying the hospital beds and that there isno inappropriate readmission into the hospital. Initially, thehealthcare system had insufficient incentives for scrutinizingadmissions in hospitals. Almost each of the patients in attendancewas admitted optimizing the hospital reimbursement and volumes.Currently, health costs are occupying a massive part of the grossnational products. Hospitals have been facing cuts in reimbursementand increasing the number of patients without insurance. The managerstake a practical move towards the administration of admissions inhospitals and ensure that patients who are admitted, fits in andprovide appropriate care (Powell,2000).

Emergencycase managers have an extra responsibility enhancement for clinicalreporting improvement personnel and liaise with physicians andemergency unit in ensuring that certification symbolizes thepatient`s conditions. Case managers are thus involved in the reviewand admission process of the case before registering it forsubmission. Once, the registration is made for the patient it ismore complex to cancel a viable access than it would stop it fromtaking place. The managers ensure that the registered patient meetsthe requirement of inpatient care. As a result, they help the givenhospital to avoid the filling of condition code 44 (Powell,2000).

Thecase managers ensure that reimbursement is not lost or face extrascrutiny from payers. The managers ensure that the admitted patientsmeet the criteria for the acute care to help the hospital to thebottom line and avoid piling up patients. For instance, patients aresubject to infections and diseases while in the hospital and may beat risk and therefore there is no need to hospitalize themunnecessarily (Powell,2000).

Themanagers have the opportunity to impact on the period of stay byinitiating preadmission discharge arrangements whilst the patient isa resident of the emergency Unit. The managers communicate with themembers of the family accompanying patients and get their medicalhistory. This data saves the managers on the issue of tracking thefamily members visiting on evening hours when the managers are offduty. They can fabricate care by obtaining procedures and testsperformed previously and ensure treatment of the suitable patients.The managers can reduce or eliminate inappropriate admission whenthey get an individual in the emergency department to situate theirservices. The service that may be situated includes home care health(Powell,2000).

GovernmentFunded Programs and Private sector

Boththe government funded programs and private sectors present bothadvantages and disadvantages. The purpose of government fundedprograms are set by legislation while the private sector focuses onthe new needs, emerging issues and the population is not recognizedas particular interest. Government programs concentrate on thefunctions that impact particular groups of the society while privatesector pools resource with other stakeholders. The government iswilling to pay all costs of the programs or cover all the overheadwhile private sector includes a broad range of sizeable grants wheresome of them can make massive awards (Powell,2000).

Forthe government programs, it is easier to get information and stay onthe current needs of the programs while the private sectors are amore reliable source of experimental or startup funds. Theapplication deadlines and processes are very firm while the privatesectors are involved in proposals. The government programs arebureaucratic while the private sector is average grant size. For thegovernment programs, the requirement for the proposals is lengthywith complicated compliance, administration and applicationprocedures while priorities for private sectors can be changedrapidly while a continuous support is often complex (Powell,2000).

Governmentfunding programs need institutional cost matching and sharing. Theapplicants for private sectors have limited influence on the processof making a decision. Reviewers tend to be for the establishedcandidates of government programs while information on procedures andpolicies of private sectors must be researched. Public programs maybe averse to the funding of the new idea or something that is yet tobe proven. Also, the federal grant funding is subject to the flow andebb of the political temperature. The private sector may face issueswith project rejection, support and voicing their problems. If thefund program is unresponsive, they may not have the capacity to seekassistance from a higher authority (Powell,2000).


Powell,S. K. (Ed.). (2000).&nbspCasemanagement: A practical guide to success in managed care.Lippincott Williams &amp Wilkins