Health Care Reimbursement and Utilization Management

Health Care Reimbursement and Utilization Management

Scenario: Medicare and private payers have expanded reimbursement under Accountable care organizations (ACO). You are the chief financial officer (CFO) of a hospital system that is forming an ACO to participate in these payment models. The ACO seeks to improve care coordination for its patients with chronic conditions. To provide better care management, the ACO is interested in investing in primary care physicians and physician’s assistants to provide more intensive care management services. After formation, the ACO will enter contracts with Medicare and private insurers under alternative payment models, including shared savings, bundled payments, and global capitation. The ACO will need to determine how to set up reimbursement payments to ACO providers and consider whether financial incentives are required to ensure ACO providers deliver efficient care. To prepare for this Discussion: Read the provided scenario. 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? Post a cohesive response to the following: As the CFO of the ACO in the provided scenario, recommend 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.