Posted: August 6th, 2022

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Reimbursement Options

Your Name

Capella University

BHA-FPX4009

Assessment 2

Introduction

[Provide a brief introduction (preview of the main theses of your paper) here and delete all statements within brackets, such as this paragraph, and replace with your discussion. Also, before you begin, review the “Scoring Guide” and understand the difference between “Distinguished,” “Proficient,” “Basic,” and “Non-Performance.” These “Scoring Guides” are used to grade the assessment. This is why each Template is set up with headings (below) that correspond with the “Scoring Guides” for this specific assessment. Please leave the Headings (below) in the paper.]

Part I – Provider Reimbursement Options

Fee-For-Service

[What is fee-for service? Explain drawbacks of the fee-for-service reimbursement model].

Capitation

[What is capitation? Explain drawbacks of the capitation reimbursement model as it relates to providing comprehensive services].

Pay-for-Performance

[What is pay for performance? Explain how pay-for-performance impacts reimbursement rates].

Resource-Based Relative Value Scale or Case-Based

[What is it? Explain how resource-based relative value scale or case-based payment encourage an overuse of services].

Part 2 – Payment Options for Uninsured Patients

Identify and Explain Payment Options for Uninsured

[Identify and explain payment options for uninsured patients, including methods by which the patient would qualify for the method identified and rationale for the associated appointment charge; provide relevant resources].

Conclusion

[Summarize the main themes of your paper.]

References

[Lastname, C. (2008). Title of the source without caps except Proper Nouns or: First word after colon. The Journal or Publication Italicized and Capped, Vol# italicized(Issue#), Page numbers.

Lastname, O. (2010). Online journal using DOI or digital object identifier. Main Online Journal Name, Vol# italicized(Issue#), 159–192. https://doi.org/10.1000/182

Lastname, W. (2009). If there is no DOI use the URL of the main website referenced. Article Without DOI Reference, Vol# italicized(Issue#), 166-212. http://www.mainwebsite.org

NOTE: The above references are SAMPLES ONLY. For more information and example related to references, visit Capella’s Writing Center. YOU ARE RESPONSIBLE FOR SUBMITTING APPROPRIATE IN-TEXT AND REFERENCE PAGE CITATIONS.]

Develop a 3-5 page review of the various reimbursement options that a large primary care office would have for the charges associated with a new patient consult.

Introduction

Reimbursement for services rendered by providers (physicians, physician assistants, and other providers) is generally made under one of two payment types: fee-for-service or episode of care reimbursement. Fee-for-service methodology is based on the premises that providers receive payment for each service rendered and is based on a set amount or price for each service. Included in this methodology are self-pay payments, retrospective payments, and managed care contracts.

Under the episode of care methodology, providers receive one lump sum for all services provided related to a given condition or disease. Understanding each method of payment, its benefits and drawbacks, as well as its impact on cost control and resource utilization is important for those working in the health industry, as reimbursement impacts many decisions made about budgets, forecasts, strategy, and service line capacities.

In this assessment, you will demonstrate your understanding of various reimbursement options within the context of a new patient consult. For this assessment, assume the role of a reimbursement specialist for a large primary care office. While you are aware that your providers are reimbursed in several different ways, the providers are uncertain as to what each reimbursement type means for the practice in terms of collections. They have requested that you outline the different reimbursement options to which the practice is subject for the providers in the group.

Demonstration of Proficiency

By successfully completing this assessment, you will demonstrate your proficiency in the following course competencies and assessment criteria:

· Competency 1: Compare current trends and traditional methods of payment in the health care industry.

. Explain payment options for uninsured patients, including how the patient would qualify for each option.

· Competency 2: Assess health care reimbursement.

. Describe drawbacks of the fee-for-service reimbursement model.

. Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services.

. Describe how pay-for-performance impacts reimbursement rates.

. Describe how resource-based relative value scale or case-based payment encourages an overuse of services.

· Competency 4: Communicate in a manner that is scholarly, professional, and respectful of the diversity, dignity, and integrity of others and is consistent with the expectations of health care professionals.

. Adhere to the rules of grammar, usage, and mechanics.

. Apply APA formatting to in-text citations and references.

Instructions

This assessment is based on the following scenario:

· Patient scenario: Your office is seeing a new patient for the first time (new patient consults are $500). 

In your role as the reimbursement specialist for a large primary care office, outline the different reimbursement options to which the practice is subject for the providers in the group.

Support your assertions with at least three academic sources. This may require you to do additional independent research. You may wish to consult the 

Health Care Administration Undergraduate Library Research Guide

 before you begin any additional research.

This assessment has two parts.

Part 1: Provider Reimbursement Options

Present (at least) the four main reimbursement options that your provider in the scenario would likely have for a new patient consult. Describe the options and comment on potential drawbacks or additional considerations to take into account with each model. Also, consider the likelihood and challenges of recouping the entirety of the consult charges for the patient.

Relevant scoring guide criteria:

· Describe drawbacks of the fee-for-service reimbursement model.

. “Describe” means to give an account in words of (someone or something), including all the relevant characteristics, qualities, or events.

· Describe drawbacks of the capitation reimbursement model as it relates to providing comprehensive services.

· Describe how pay-for-performance impacts reimbursement rates.

· Describe how resource-based relative value scale or case-based payment encourages an overuse of services.

· Adhere to the rules of grammar, usage, and mechanics.

. “Grammar” refers to the basic rules for how sentences are constructed and how words combine to make sentences (for example, word order, case, and tense).

. “Usage” refers to correct word choice and phrasing, particularly with regard to the meanings of words and phrases.

. “Mechanics” refers to correct use of capitalization, punctuation, and spelling.

· Apply APA formatting to in-text citations and references.

. Be sure to include a separate References page.

One potential way to organize this part would be as follows:

· Fee-for-service.

. What is it?

. Consider health care spending and cost control; what are the drawbacks of this model?

· Capitation.

. What is it?

. What are the potential drawbacks of this model for the physicians who are driven to provide comprehensive services to their patients?

· Pay for performance.

. What is it?

. How does this model impact reimbursement rates?

· Resource-based relative value scale or case-based payment.

. What is it?

. How can this model potentially encourage an overuse of services?

Part 2: Payment Options for Uninsured Patients

Identify and explain the potential payment options that would be available to the patient and your care provider if the patient in for the new patient consult had been uninsured. Also, be sure to discuss the ways that a patient could qualify for specific payment options, as well as the rationale for the associated appointment charge.

Relevant scoring guide criteria:

· Explain payment options for uninsured patients, including how the patient would qualify for each option.

. “Explain” means to make (an idea, situation, or problem) clear to someone by describing it in more detail or revealing relevant facts or ideas.

· Adhere to the rules of grammar, usage, and mechanics.
· Apply APA formatting to in-text citations and references.

One potential way to organize this part would be:

· Medicaid.

. How does the patient qualify?

· Financing options.

. What is this method?

· Self-pay.

. How would the patient be charged? A percentage of commercial contracts or a percentage of Medicare?

· Charity care.

. How would you screen a patient for charity care?

. What process would you implement to qualify a patient for charity care?

Additional Submission Requirements

· Structure: Use the 

Reimbursement Options template [DOC]

 provided. Include a title page and references page when submitting your assessment.

· Length: 3–5 pages, plus title and references pages.

· References: Cite at least three current scholarly or professional resources.

. Your textbook can be one of the three.

· Format: Use APA style for references and citations only. Refer to:

.

APA Style Paper Tutorial [DOCX]

.

. Additional APA resources located in the courseroom navigation panel.

· Font: Times New Roman font, 12 point, double-spaced.

7/31/22, 10:27 PM

Reimbursement Options Scoring Guide

https://courserooma.capella.edu/bbcswebdav/institution/BHA-FPX/BHA-FPX4009/210100/Scoring_Guides/a02_scoring_guide.html 1/2

Reimbursement Options Scoring Guide

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Describe drawbacks
of the fee-for-service
reimbursement
model.

Does not identify
any drawbacks of
the fee-for-service
reimbursement
model.

Attempts to describe
drawbacks of the fee-
for-service
reimbursement model,
but the description is
inaccurate or
incomplete.

Describes
drawbacks of
the fee-for-
service
reimbursement
model.

Explains drawbacks of the fee-
for-service reimbursement
model, including the likelihood
and challenges of recouping
the entirety of the consult
charges for the patient.

Describe drawbacks
of the capitation
reimbursement
model as it relates
to providing
comprehensive
services.

Does not identify
any drawbacks of
the capitation
reimbursement
model as it
relates to
providing
comprehensive
services.

Attempts to describe
drawbacks of the
capitation
reimbursement model
as it relates to providing
comprehensive
services, but the
description is inaccurate
or incomplete.

Describes
drawbacks of
the capitation
reimbursement
model as it
relates to
providing
comprehensive
services.

Explains drawbacks of the
capitation reimbursement
model as it relates to providing
comprehensive services,
including the likelihood and
challenges of recouping the
entirety of the consult charges
for the patient.

Describe how pay-
for-performance
impacts
reimbursement
rates.

Does not identify
how pay-for-
performance
impacts
reimbursement
rates.

Attempts to describe
how pay-for-
performance impacts
reimbursement rates,
but the description is
inaccurate or
incomplete.

Describes how
pay-for-
performance
impacts
reimbursement
rates.

Explains how pay-for-
performance impacts
reimbursement rates, including
examples supported by
citations to professional or
scholarly literature.

Describe how
resource-based
relative value scale
or case-based
payment
encourages an
overuse of services.

Does not attempt
to identify how
resource-based
relative value
scale or case-
based payment
encourages an
overuse of
services.

Attempts to describe
how resource-based
relative value scale or
case-based payment
encourages an overuse
of services, but the
description is inaccurate
or incomplete.

Describes how
resource-based
relative value
scale or case-
based payment
encourages an
overuse of
services.

Explains how resource-based
relative value scale or case-
based payment encourages an
overuse of services and
provides specific examples
and sources.

Explain payment
options for
uninsured patients,
including how the
patient would
qualify for each
option.

Does not attempt
to describe
payment options
for uninsured
patients.

Attempts to describe
payment options for
uninsured patients, but
the description is
inaccurate or
incomplete.

Explains
payment
options for
uninsured
patients,
including how
the patient
would qualify
for each option.

Explains payment options for
uninsured patients, including
how the patient would qualify
for each option, and provides
examples and relevant
resources to support the
examples.

Adhere to the rules
of grammar, usage,
and mechanics.

Does not adhere
to the rules of
grammar, usage,
and mechanics.

Errors in grammar,
usage, and mechanics
inhibit readability and
comprehension and
detract from good
scholarship.

Adheres to the
rules of
grammar,
usage, and
mechanics.

Exhibits strict and nearly
flawless adherence to the rules
of grammar, usage, and
mechanics.

7/31/22, 10:27 PM Reimbursement Options Scoring Guide

https://courserooma.capella.edu/bbcswebdav/institution/BHA-FPX/BHA-FPX4009/210100/Scoring_Guides/a02_scoring_guide.html 2/2

CRITERIA NON-PERFORMANCE BASIC PROFICIENT DISTINGUISHED

Apply APA
formatting to in-text
citations and
references.

Does not apply
APA formatting to
in-text citations
and references.

Applies APA formatting
to in-text citations and
references incorrectly or
inconsistently, detracting
noticeably from good
scholarship.

Applies APA
formatting to in-
text citations
and references.

Exhibits strict and nearly
flawless adherence to APA
formatting of in-text citations
and references.

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