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HI215 Reimbursement Methodologies Unit 4 Assignment Instructions and Worksheet (Use this document as a worksheet to complete this assignment) Objective: To evaluate the course outcome HI215-1: Examine the reimbursement processes of different health insurance plans. Point Value: 250 points. Assignment Activities include the following: 1. Review the Health Finance Case Study on “Primary Care Financial Management” (20 points) Questions: 1. What would you recommend that ABC Primary do to tighten up the financial of the practice? List at least three items along with your rational. • It is essential to record all monetary data with the goal that each dollar can be represented. ABC did not keep up work force action reports which imply that it was obscure whether compensation and periphery benefits were admissible. • ABC needs to isolate uses identified with Government stipends and those identified with other financing sources. ABC needs to make it a best need to be responsible for the money related administration framework. Bank articulations were not made, kept up and accommodated in an opportune way which made their budgetary data inconsistent. • ABC needs to refresh acquirement systems also keeping in mind the end goal to ensure that they are getting products and ventures at sensible costs. 2. Review the provided OIG website link for any additional information and background. 2. Review the Health Finance Case Study on “Claims Management”. (10 points each/20 points) 1. What should WPS do with CMS to improve the process? Review the provided OIG web link for additional background and information. • The installment issues that happened were a direct result of charging issues inside the clinics which imply that billers and coders should be more tenacious and focus on detail when preparing claims. It might be useful to have a consistence officer that knows about directions and strategies and that can perform arbitrary reviews to guarantee that coders and coding legitimately which thusly enables the billers to charge the methodology appropriately. WPS and CMS might need to make a check procedure also so the data is exact inside the two domains. 2. As an executive for the Wisconsin Physicians Service (WPS) Insurance Corporation, after reviewing the case, what recommendations would you propose to the Board of Directors that they should prepare for as a response from the OIG? List at least three recommendations along with your rational. 3. Practice Assignment on Fee Calculations: (40 Points) 1. Kaplan Anytown Hospital’s charges, payments, and adjustments from third-party payers for the month of July are represented in table 4-W. a. Calculate the percentage of charges, payments, and adjustments for each third- party payer and enter the percentages in the percentages columns of table 4-W (25 points) Table 4-W Payer Charges Payments Adjustmen t Charges Payments Adjustments BC/BS $450,000 $360,000 $90,000 23 % 31 % 12 % Commercial $250,000 $200,000 $50,000 13 % 17 % 6 % Medicaid* $350,000 $75,000 $275,000 18 % 0.06 % 36 % Medicare $750,000 $495,000 $255,000 38 % 42 % 33 % TRICARE* $150,000 $50,000 $100,000 0.08 % 0.04 % 13 % Totals $1,950,000 $1,180,000 $770,000 100% 100% 100% * Managed care capitated payment for period b. Based on the percentages calculated in the charges column, identify the payer the facility does the most business with and the payer it does the least business with. (5pts.) c. Based on the percentages calculated in the payment column, identify the payers that reimburse the facility the most and the least. (5 pts) d. Based on the percentages calculated in the adjustments column, identify the payers that proportionately reimburse the facility the most and the least. (5 pts) 4. Insurance Plan Review: Refer to the figure 5.4 in the Harrington text on the Insurance Plan Option one. Answer the following questions (15 points; 5 pts each): 1. What is the difference between the out-of-pocket limits for participating providers per person and per family versus non-participating providers per person per family? ...........................................continued..................................................