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US Healthcare Reimbursement and Insurance Issues Essay

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Document Type:Essay


HealthCare Insurance and Reimbursement

Medical Insurance Products and Services

Health and medical insurance represent an insurance coverage form that disburses operation and clinical treatment expenditure incurred by those insured. Such insurance may either reimburse insured individuals for the money they put into treatment for injuries or disease or may directly pay care practitioners. It is commonly a part of the compensation packages offered by organizations to their employees for attracting quality recruits (IMedPub, 2020). It constitutes one means by which individuals in different nations pay for their healthcare needs. When individuals hailing from poor backgrounds without any financial risk protection get sick or injured, they encounter the following difficulty: they may either make use of healthcare services, further impoverishing themselves by financing these services, or may forego treatment, stay sick/injured, and risk not being able to function properly or go to work. Regardless of the differences in funding and corporate structures in different nations, high-income nations currently witness an almost undisputed dedication to guaranteeing universal healthcare access to their citizens. Globally, healthcare insurance coverage attempts at improving health service utilization as well as safeguarding families against destitution due to out-of-pocket expenses (Ho, 2015).

Managed healthcare insurance plans represent a substitute for conventional healthcare plans, such as paid service plans. Over the last few decades, such schemes have grown into a widely-chosen health insurance form, with the growth of healthcare expenses. The kind of managed scheme of an individual determines how the individual acquires healthcare services. Some of the key kinds of network healthcare plans are:

· Health Maintenance Organization (HMO)

· Point of Service Plan (POS)

· Preferred Provider Organization (PPO)

· Exclusive Provider Organization (EPO)

The most flexible plans will, perhaps, be the costliest on account of the associated lack of previously agreed-upon network member contracts. While plans differ, HMOs are usually the cheapest alternative when it comes to managed care. Meanwhile, PPOs are moderately expensive; the POS is, perhaps, owing to its maximum flexibility, costlier as compared to HMOs; and the EPO, perhaps, entails out-of-pocket expenses if one gets services outside member organizations or network (Araujo, 2020).

Role of Health Care Providers, Insurers and Integrated Delivery Systems

Healthcare insurers’ market power is leveraged to obtain price discounts from healthcare organizations and systems or providers or for screening out costly providers from the networks. Insured individuals profit from such discounts even if they are paying out of their pockets for healthcare services (except for prescription drugs, as patients, even those who are insured, typically pay the list price). Policies concentrating on this health insurance function impact healthcare organizations’ and providers’ negotiating leverage about insurers. For instance, Medicare establishes payment rates using fee schedules, instead of enabling healthcare systems to utilize their leverage in the market for driving up charged rates. The ACA (Affordable Care Act) urged insurers to forge “narrow” healthcare organization and provider networks for aiding commercial plans in obtaining reduced rates using greater negotiating leverage. Further, the consolidation of insurance firms reinforces the negotiating position of the insurer (Dey & Bach, 2019).

The goal of offering improved catastrophic monetary protection that is dependent upon pooling the risks of several individuals who won’t be enduring such events is contrary to the goal of selling highly-personalized insurance to different clients based on their unique anticipated needs. Encouragement of narrow networks may help reduce prices, though at the expense of omitting quality practitioners. Governmental, as well as commercial insurers, have come up with measurement efforts aimed at monitoring and improving healthcare organization quality. Some examples are quality ratings that aid…

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Operation Finance and Budgeting

The health sector is one of the sole global sectors, which will be imperative in the long run, unforeseeable. This domain has been undergoing constant growth and progress for several centuries, with no indication of ever slowing down. Day after day, technological advancements in some or other areas contributing to the health sector are witnessed. Right from drugs to clinical instruments, healthcare sector improvements have the potential to change, improve, and save lives worldwide. With the expansion in human knowledge of such matters is a simultaneous expansion of inpatient care. Ultimately, better patient results are the aim of all healthcare organizations and facilities, irrespective of any other differences that may exist between healthcare practitioners (Strata Decision Technology, 2020).

Decision-making represents a central factor when deciding small and large provider success in the long run, though it isn’t the sole factor to be considered by healthcare organizations. Healthcare organizations seeking both long life and heightened current patient outcomes must consider financial planning. Those bracing for the future are also better equipped to handle coming change. With the swift evolution of healthcare markets, it is sometimes difficult to ascertain where best to allocate funds and how to balance capital budgets. But organizations prepared for the numerous future possibilities may more effectively and strategically plan for the future in terms of finance. Financial security can be secured by organizations planning well in advance where to spend funds while seeking areas for cost improvements. Healthcare practitioners not constantly seeking areas for improving efficiency usually end up wasting considerable money. While there is a need to devote some funds to compulsory entities dutifully, other areas like substitute devices, several metrics, vendor negotiations and leverage, and contract analysis must be thoroughly studied before allotting funds. Here, funds are generally…

Sample Source(s) Used


Araujo, M. (2020). Health and medical insurance differences: HMO, PPO, POS, EPO. Retrieved from

Bertram, M. Y., Lauer, J. A., De Joncheere, K. D., Edejer, T., Hutubessy, R., Kieny, M. P., & Hill, S. R. (2016). Cost-effectiveness thresholds: pros and cons. Bull World Health Organ, 94, 925–930.

Dey, P., & Bach, P. B. (2019). The 6 functions of health insurance. The JAMA Forum, 321(13), 1242-1243.  DOI:10.1001/jama.2019.2320

Ho, A. (2015). Health insurance. Encyclopedia of Global Bioethics. Retrieved from

IMedPub. (2020). Health insurance. Retrieved from

Maruthappu, M., Hasan, A., & Zeltner, T. (2016). Enablers and barriers in implementing integrated care. Health System & Reform, 1(4), 250-256.

Sekhri, N. (2000). Managed care: The US experience. Bulletin of the World Health Organization, 78(6), 830-844. Retrieved from

Strata Decision Technology. (2020). Healthcare and hospital capital budget. Retrieved from

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