CAU Healthcare Payment Systems and Insurance Options Discussion

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Insurance Options Reply to each Peer about their post.

Insurance Options Reply 1 to Yanira:

Hello everyone,

For this week’s discussion, we’re discussing the payment, and the claims charged to each patient when they come to the hospital when seeking medical treatment. We will be discussing the types of payments when submitting claims due to a hospital visit and how much or what type of payment the patient is looking for with insurance and without insurance. For the most part, hospitals are excellent about taking any major health insurance, even if it’s an HMO plan. Hospital visits are easier to get approved through insurance since the visit is urgent care. According to Abbey, D. (2010), “The number and type of healthcare payment systems are almost beyond comprehension. Even within a broad category of a payment system, there can be dozens, if not hundreds, of variations. Thus, learning and mastering any given type of payment system must allow for significant degrees of variation and ongoing changes.” Insurance companies all have different payment plans, and some fully cover the patient, and some don’t, leaving the patient with some balance at times.

Sam, the older man that received minor injuries due to being rear ending a car, was brought to the hospital. I already understand that it was a car accident. We understand that perhaps, Sam was brought to the nearest hospital, a hospital that might be out of network with his insurance carrier. According to Francisca Goldsmith. (2015) “Insurance premiums collected must be spent against costs incurred by those insured at an 80/20 ratio, with no more than 20 percent of the premium applied to the insurer’s administrative costs and 80 percent applied directly to the health-care expenses of those they insure.” Similar to the case study in the healthcare system book. Understanding that maybe since it says that Sam is an “elderly man,” he might have Medicare insurance who will cover 80% percent of his visit. The 20% will be charged to him or his secondary insurance if the contract with one.

References:

Abbey, D. (2010). Healthcare payment systems: An introduction. Boca Raton, FL: Productivity Press.

Francisca Goldsmith. (, 2015). Libraries and the Affordable Care Act?: Helping the Community Understand Their Health-Care Options. ALA Editions.

Insurance Options Reply to Paolo:

For this week’s discussion, focus is on healthcare payment systems. According to Abbey (2010), there are numerous types and examples of healthcare payments systems. It is important to comprehend, at least in the general sense, these payment systems to better set the organization financially and allocate scarce resources effectively based on perceived reimbursement for services.

Key to understanding the general concept of healthcare payment systems is the third-party payer concept. The first party is the individual seeking medical serviced from a provider such as a hospital, the second party. If this case was a private pay, the first party pays the second party for the services rendered. However, if the first party has medical insurance coverage such as Medicare, the insurance provider becomes the third party and the hospital must follow the regulations set forth by the third party in order to be paid for the services (Abbey, 2010). To illustrate this, consider patient #1 in this week’s discussion. According to West Coast University (2020), patient #1’s case is as follows: “Sam, an elderly man, rear ended a motorcycle. Sam received only minor injuries but was brought to the hospital” (Section 1). Sam is the first party while the hospital is the second party. There are factors involved in determining the third party in this case. According to Medicaid.gov (2020), there is the possibility that beneficiaries may have one or more additional sources for the healthcare coverage. In the case of Sam, Medicare may be assumed as a source of payment as he is an elderly individual. Nevertheless, involvement in a motorcycle accident may necessitate auto insurance coverage of the at-fault party. Hence, there can be two payment sources or third parties in Sam’s case. First will the auto insurance and Medicare, if covered, will be the second (Abbey, 2010).

It is important to learn key concepts of healthcare delivery systems and understanding the third-payer concept is good foundation for further learning and comprehension.

Reference:

Abbey, D. C. (2010). Healthcare payment systems: An introduction. CRC Press.

Medicaid.gov. (2020). Coordination of benefits & third party liability. https://www.medicaid.gov/medicaid/eligibility/coordination-of-benefits-third-party-liability/index.html

West Coast University. (2020). HA 340: Healthcare payment systems week 2 discussion prompt. https://learn.westcoastuniversity.edu/webapps/discussionboard/do/message?action=list_messages&course_id=_61939_1&nav=discussion_board_entry&conf_id=_67456_1&forum_id=_272855_1&message_id=_9046438_1