Health Care Reimbursement: Retrospective & Prospective Strategies - Essay Sample

Introduction

Health care reimbursement refers to the payment which your diagnostic facility, hospital, and doctor, receives due to the medical service they give you (Hosseini-Eshpala et al.,2015). In some cases, the insurer or the government payer pays the cost of the health care service. While implementing a health care system to use, the payers or the providers use two significant strategies to determine which method to use. According to the attached paper, such systems are retrospective and prospective health care payment systems. The prospective payment system allows the payer to make determinations of the cost of care before the provision of the service to the patient. In retrospective, the responsibility is provided, and after that, the price is determined (Hosseini-Eshpala et al.,2015).

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Prospective payment system involves the creation of the budget only when the care criteria episode is reached. After the budget, the fee is paid to the organization of the payer to make distributions to relevant clinicians. In retrospective payment model involves the advance calculation of the cost as well as reconciling against claims service fee of medical to make determinations of savings shared after the end of the care episode (Hosseini-Eshpala et al.,2015). These two systems help in the decision of the type of system to be used with minimal risks and most efficient to the care needed by the patient. The risk transfer performance helps the provider to recognize any financial reward to get after delivering complete care at a price that is less than the cost of negotiation during the reporting of the case.

There is a need of the payers to understand both positives as well as the negatives of using these two systems before they make any settling decision any particular plan of reimbursement. Like in the case of prospective method, the payers have to ensure that they make a track on a fee for the service claims against the calculated price, this will help them in evaluating the future pricing of the payment system of the health care. For completion of this step, the payers can use either manual processes or implementing automated technology (Hosseini-Eshpala et al.,2015). The pricing of this system can turn into two ways. That is, accurately priced that involves flat average payment rate and one which accounts for the severity of patient through the use of risk adjustment.

While the retrospective system, it incorporates the reconciled budget with the acing health care plan as a commercial integrator to the paid fee instead of giving the responsibility to one provider. The positive part of this system of payment is that it includes the payer's ability to work with the organization as the prospective system has many regulatory hurdles who pays the outcome. Besides, since it is difficult in the side of potential treatments as well as the patient's behavior, payment reconciliation through this system is of more benefit for the providers (Hosseini-Eshpala et al.,2015). The agreement has more favour to the patient in the use of the retrospective system than in the use of a prospective system.

Compare and Contrast the Systems in Relation to Hospitals

Both prospective and retrospective systems in the hospitals are used for the fixing of payment rates to any treatment to take place. The prospective payment system is concerned with the assignment of the fixed rates of payment of the specified procedures (Gilbert et al.,(2015). As the prices might alter due to inflation factors, these system plans are not adjusted to ensure accommodation of individual patient. The payments to the provider remain constant in the provision of the same specified type of treatment.

While in the retrospective system, the provider determines the amount to be paid for the fee of the service (Gilbert et al.,(2015). The price can be altered in the provision of the same specified type of treatment. The provider using this system in the hospital attends the patient and submits the utilized bill to the insurance company with details of the service offered to the patient (Gilbert et al.,(2015). After this, the insurance company has the powers to approve or deny the treatment payment or thereof portions, but the healthcare providers get paid total amounts he or she bills.

In the hospital, using prospective systems patients receives loss attention as the providers are limited only to the approved plans of treatments. They cannot make any adjustments to their services to ensure that they meet the needs of individual patients. In comparison to the retrospective system, there is more attention to the patients as the providers have no limit to the approved plans of treatments (Gilbert et al.,(2015). These providers can make any adjustments to ensure that they accommodate the needs of each patient.

Compare and Contrast the Systems in Relation to Patients

In attending the patient's needs of care, it takes the providers to use two different systems in which they have to choose which one to use in place of the other. Such systems are retrospective and prospective systems. Retrospective system allows the patient to get treatments and pay the bill of care after the service (Gilbert et al.,(2015). These systems use different types of reimbursement formula which are based on the incurred expenses. Some of this method offers less incentive for facilities to restrict the costs to the patients hence encouraging the expansion of the staff, wages rise, and development of improvement capital (Gilbert et al.,(2015). Such formulae are retrospective cost-based and retrospective cost-related. However, these systems may have some limits to the attending of patients due to various ceiling on the centres of costs as well as constraints on cost allowable to them.

The use of a prospective system in contrast to the retrospective system, prepare the patients in how much to pay in advance before the service of treatments is offered to them (Edmonds et al.,2017). These advance rates determination helps the provider by giving them incentives to enable them to keep their expenditures within the allowed amounts. It also provides the providers with incentives to reduce quality as well as services to allow for some various kinds of monitoring systems needed in prospective reimbursement systems compared to the retrospective systems.

For the management of high rates of patients in the hospitals, prospective systems have to be used in place of retrospective systems (Edmonds et al.,2017). The reason for the use of the prospective system is because it allows multiple tasks on determining the needs of the patients, unlike the retrospective systems, which carries a particular need at a time. Therefore, the prospective is of high rate speed.

Compare and Contrast the Systems in Relation to Taxpayers

Taxpayers in hospitals refer to those providers who pay for the bills of the patients, and they are based on the taxes in the case. The hospitals use some systems in the determinations of the amount to be paid by any patient for the needs of the care. Prospective and retrospective methods are mainly used in these operations of the price determinations (Edmonds et al.,2017). The two systems act differently in their services for daily activities.

In the case where the hospitals decide to use the prospective method, it adds some advantage to the taxpayer as it determines the price needed in advance as well as fixing the to the fiscal period to which they apply (Edmonds et al.,2017). This adds more value to the taxpayers as they will be able to determine the amount to spend and any other requirements needed for the care of the patient. Unlike the retrospective systems that allows the patient's need to be catered for and pay for the service offered to the patient.

The prospective system payments for any patient in the hospitals are not determined automatically by the pattern or level of its past or the present incurred charges as well as costs. Such payments are not the same as in the case of a retrospective system where its amounts are determined automatically by the levels of their past and present charges or the costs (Edmonds et al.,2017). Therefore, it is of more benefit to using the prospective system on the determination of the patient's needs with regards to the taxpayers' payments analysis.

Besides, potential policies constitute full payments for any specific unit of the services offered to the patients. Such represents favour a lot the taxpayers as it enables them to make the decisions in getting the sources of the required money for the service (Edmonds et al.,2017). This is contrary to the retrospective system where the payments constitute to payments in less per the required amount for the unit of offered service. Thus, in most cases, hospitals use of prospective systems in consideration of the taxpayers.

Prospective reimbursement system has a characteristic that enables many hospitals to keep or lose any difference between the rate of payments as well as the costs per unit of care. Such a feature is not present in the retrospective system. Therefore, the taxpayer is in a position to access the rate to be charged in any care needed to attend the patient (Edmonds et al.,2017). These characteristics help in the provision of substantial financial incentives to be used in the hospitals to control input costs as well as resources used in the operations hence reducing the amount of money required to be paid by the taxpayer for such service.

Conclusion

In conclusion, it more preferable for hospitals to use prospective systems in the determination of the patient's needs and the amount of payments needed to cater to the service provided. The reason for the use of it is due to its advance determination of requirements required. It ensures that the payments are determined in advance before any service is provided. Such decisions favour both the hospitals and the taxpayers as well as the patients. It enables the hospitals to make the right charges for the services. It still prepares the taxpayer on the amount needed to cater to the service of care to the

References

Edmonds, C. M., Ribbe, C., Thielman, E. J., & Henry, J. A. (2017). Progressive tinnitus management level 3 skills education: A 5-year clinical retrospective. American Journal of Audiology, 26(3), 242-250.

Gilbert, F., Tucker, L., Gillan, M., Willsher, P., Cooke, J., Duncan, K., ... & Strudley, C. (2015). The TOMMY trial: a comparison of TOMosynthesis with digital MammographY in the UK NHS Breast Screening Programme-a multicentre retrospective reading study comparing the diagnostic performance of digital breast tomosynthesis and digital mammography with digital mammography alone.

Hosseini-Eshpala, R., Khorramy, F., Baniasadi, T., Azarmehr, N., Mohammady, F., Hayavy Haghighi, M. H., & Dehghani, M. (2015). The Comparison of the cost of patient records in a global system with corresponding retrospective reimbursement system: a case study in Iran. Journal of Modern Medical Information Sciences, 1(1), 65-74.