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Pages:
6 pages/β‰ˆ1650 words
Sources:
3 Sources
Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Coursework
Language:
English (U.S.)
Document:
MS Word
Date:
Total cost:
$ 34.99
Topic:

Paying for Hospital and Physician Services

Coursework Instructions:

PAYING FOR HOSPITAL AND PHYSICIAN SERVICES
Assignment Overview
Third-party payers are the insurers that reimburse physicians and health care systems for services rendered – which identifies them as a central source of revenue for physicians and health care systems. This includes the two main categories of payers: the private insurances (such as Blue Cross/Blue Shield, etc.), and the public/government programs (such as Medicare/Medicaid/SCHIPs).
Third-party payers use a variety of reimbursement methods to pay providers and hospitals, depending on the specific payer involved and also the specific service(s) provided (outpatient or inpatient). The calculations vary and can be complicated, but they are critical to understand in terms of the basic math behind them. It’s also important to understand how the different payers compare in terms of reimbursement levels. Let’s move forward to examine how services are paid for by the third-party payers.
Case Assignment
Using the information in the Module 4 overview and required readings, as well as some additional research in peer-reviewed sources, complete your Case assignment by answering the questions in the following two-part assignment. Please show all formulas and calculations of your work in your paper.
Part I - Paying for Hospital Services – Overview
Mrs. Jones is a 74-year-old woman who is currently hospitalized for an ischemic stroke. She’s at a large urban Philadelphia hospital, and in the past few days, she’s incurred $189,000 in Medicare-approved charges for her care. Using the information provided in this Module, as well as the Hospital Payments Example (found in the Course’s table of contents link under “Presentations”), use the DRG table below to answer the following questions. Be sure to include all formulas and calculations used in your paper.
DRG Description Case Weight
163.3 Ischemic stroke 2.0150
338.0 Appendix removal 1.8911
870.1 Septicemia/severe sepsis 4.3296
Part I – Assignment
In approximately three pages, answer the following questions related to Mrs. Jones’ ischemic stroke. Show all formulas and calculations of your work.
1. What is the operating payment to be paid to the hospital?
2. What is the capital payment to be paid to the hospital?
3. Will the hospital be eligible for the Medicare outlier payment for this patient?
4. What is the total payment due to the hospital?
Part II – Paying for Physician Services – Overview
Mr. Thompson is an 83-year-old Medicare beneficiary. He is under the care of Dr. Heintz. Assume the following values for services provided by Dr. Heintz:
Categories RVU Geographic Cost Index Product
Work 28.16 1.371 24.35
Practice Expense 37.47 1.925 68.08
Malpractice 11.49 0.668 4.24
Conversion Factor: 51.52
Part II – Assignment
In approximately three pages, answer the following questions. Show all formulas and calculations of your work.
How much will Medicare pay Dr. Heintz if he is a Medicare participating physician? How much out-of-pocket payment will Mr. Thompson be responsible for?
How much will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who elects assignment? How much out-of-pocket payment will Mr. Thompson be responsible for?
How much will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who does not elect assignment? How much out-of-pocket payment will Mr. Thompson be responsible for?
Assignment Expectations
Conduct additional research to gather sufficient information to support your analysis.
Provide a response of 3-5 pages, not including title page and references. It is required that you show the formulas and calculations performed to arrive at your answers.
There are multiple required items to be addressed herein; please use subheadings to show where you are responding to each required item and to ensure that none are omitted.
Support your paper with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals:
Angelo State University Library. (n.d.).Library Guides: How to recognize peer-reviewed (refereed) journals. 
You may use the following source to assist in formatting your assignment:
Purdue Online Writing Lab. (n.d.). General APA guidelines. 
For additional information on reliability of sources, review the following source:
Georgetown University Library. (n.d.). Evaluating internet resources. 

Coursework Sample Content Preview:


Paying for Hospital and Physician Services
Your Name
Subject and section
Professor’s Name
Date
Introduction
Understanding healthcare financing is essential for most healthcare providers; it allows them to aid patients in making informed decisions about their healthcare options. This is especially considering the fact that healthcare financing in the United States is a complex and multifaceted system, primarily driven by third-party payers. These entities, including private insurance companies like Blue Cross/Blue Shield and public programs such as Medicare and Medicaid, are pivotal in American healthcare. Additionally, these third-party providers do not only finance a significant portion of healthcare expenses but also influence healthcare delivery and policy. Thus, having a clear grasp of the mechanisms by which these third-party payers reimburse hospitals and physicians for services rendered is crucial for better delivery of care.
On the one hand, the author notes that these methods determine the financial viability of hospitals and healthcare services and, in many cases, guide clinical decisions and patient care strategies. On the other hand, these payment structures often affect the accessibility and affordability of healthcare services for the average patient. In other words, given the dynamic nature of healthcare policies and reimbursement models, staying abreast of these changes is essential for all stakeholders in the healthcare sector.
In line with this, the author of this paper would like to analyze two scenarios that would demonstrate how specific personal information and demographics could affect healthcare reimbursements. On the one hand, this includes the case of Mrs. Jones, a 74-year-old woman hospitalized for an ischemic stroke, to understand the hospital service payment mechanisms under Medicare, with a particular focus on 

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