HLTH 8401 Week 4 Discussion: Healthcare Reimbursement and Utilization Management
Accountable care organizations (ACOs) are designed to promote value and quality in healthcare. They use new payment and delivery models that include incentives to improve care coordination and utilization management. With these models, ACOs contract with private insurers and/or Medicare to receive reimbursement, and then the ACO determines how to contract with physicians and other medical providers to provide healthcare services to patients. Since not all providers are direct employees of ACOs, there are potential challenges with reimbursing the affiliated providers in a way to maximize efficiency, increase quality, and lower utilization. For this Discussion, examine the following scenario and recommend strategies for reimbursement and utilization management.
Resources
Be sure to review the Learning Resources before completing this activity.
To prepare for this Discussion:
- Review the provided scenario and the Learning Resources.
- Consider strategies for reimbursement and utilization management, including financial incentives.
- How might you set up the reimbursement payments to ACO providers, considering the alternative payment models (i.e., fee for service, shared savings, bundled payments, or global capitations)?
- What utilization management controls might you add to align the interests of ACO providers?
By Wednesday
Post a cohesive response to the following:
- As the CFO of the ACO in the provided scenario, propose recommended strategies for reimbursement and utilization management.
- Defend your recommendations.
Support your response by identifying and explaining key points and/or examples presented in the Learning Resources.
Read a selection of your colleagues’ postings. Consider how your colleagues’ postings relate to the information presented in the Learning Resources and to your own posting.
Refer to the Week 4 Discussion Rubric for specific grading elements and criteria. Your Instructor will use this grading rubric to assess your work.
By Friday
Respond to at least two of your colleagues’ postings in one or more of the following ways:
- Expand on this Discussion by contrasting your colleagues’ recommendations with your own.
- Provide additional or alternative perspectives.
Continue engaging in the Discussion through Sunday.
SOLUTION HLTH 8401 Week 4 Discussion: Healthcare Reimbursement and Utilization Management
Hello Class,
Strategies for Reimbursement and Utilization Management
As the Chief Financial Officer (CFO) of the Accountable Care Organization (ACO) in the provided scenario, implementing effective reimbursement and utilization management strategies is critical to achieving financial sustainability and improving care quality. This proposal outlines recommended strategies for reimbursement and utilization management tailored to the ACO’s needs….
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