Reimbursement
Payment for healthcare services is one of the issues that has been the subject of numerous debates and most reformed aspects of the healthcare sector in the United States. This issue has attracted considerable attention because of the increased focus on enhancing the affordability of healthcare services without compromising quality. Consequently, various reimbursement models have been established to help address how providers are paid. There are many types of payers responsible for reimbursement as few patients usually can or do pay for their healthcare services privately. According to Donnelly et al. (2019), the different types of payers can be classified into three i.e. single-payer, multiple-payer, and state-based financing. Multiple payer refers to a health sector financed by various entities including the government and private health insurance.
In the scenario referenced in Topic 8, the type of payer responsible for reimbursement is a public payer funded by the federal or state government. Medicaid is an example of a taxpayer-funded or public payer that would be responsible for reimbursement of healthcare services for this patient. Medicaid has undergone reforms and changes in recent years, which have resulted in the expansion of the program. Lee et al. (2020) state that Medicaid expansion has positive impacts on self-reported diabetes management. The patient’s history of type 2 diabetes and age makes him ideal for Medicaid payment of care services.
While Medicaid program would be responsible for reimbursement for this patient, a reimbursement claim could be denied by this payer. If the denial is unjustifiable, there are various steps that can be undertaken to appeal within a 90-day period. The first step would entail writing an appeal letter in which the item under appeal is cited and an explanation of why the Medicaid decision is wrong. The next step is to prepare for the appeal hearing once the date is set and appearing in person or asking for representation by an attorney.
References
Donnolley, P.D., Erwin, P.C., Fox, D.M. & Grogan, C. (2019, November). Single-Payer, Multiple-Payer, and State-Based Financing of Health Care: Introduction to the Special Section. American Journal of Public Health, 109(11), 1482-1483.
Lee, J., Callaghan, T., Ory, M., Zhao, H. & Bolin, J.N. (2020, May). The Impact of Medicaid Expansion on Diabetes Management. Diabetes Care, 43(5), 1094-1101. Retrieved from https://care.diabetesjournals.org/content/43/5/1094
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