Case Study: the payer–patient mix for a health care organization

Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following: Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare). Using the same CPT code, 99214, determine the reimbursement for Medicaid (fee schedules should be available from the individual state). Using the same CPT code, 99214, create at least 3 other traditional indemnity insurance reimbursements. If possible, use the actual reimbursement from the insurance carrier. It may be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid. Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days. Assess the information for areas of improved reimbursement of at least 20% or more. Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues. Propose a best strategy with justification and rationale based on effective decision-making tenets.
***Spreadsheets demonstrating the accounts receivable analysis will be attached as appendices***Also attach appropriate fee schedules.
**** REFERENCES MUST BE WITHIN 5 YEARS******* Support ideas by drawing from (and citing) “good” sources; i.e., recent, relevant, credible materials. The selection of references should represent the best available references on the topic. Avoid using information posted on websites – visit http://library.ucsc.edu/help/research/evaluate-content-from-the-web for information on evaluating websites. Do not use sources like Wikipedia and Answers.com – these may provide good background information; but these are not scholarly. Some other unacceptable sources include: cliffsnotes.com, managementhelp.org, managementstudyguide.com,mindtools.com, smallbusiness.chron.com, vectorstudy.com, and so on. If in doubt, ask. Instead of performing an internet search (using Google or other similar search engines) to find something to support ideas, take advantage of the university’s online library.

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