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One type of health insurance that can be challenging on submitting a reimbursement and obtaining payment is a health maintenance organization (HMO) when a patient is seeking care from a non-HMO provid
One type of health insurance that can be challenging on submitting a reimbursement and obtaining payment is a health maintenance organization (HMO) when a patient is seeking care from a non-HMO provider unless it’s in an emergency. A patient that has an HMO plan must seek care and services only from their primary care physician (PCP) (HMOs, PPO, & POS Plans, 2019). The patient’s PCP must authorize another physician for other care through a referral for the patient to see that specific physician. If a referral hasn’t been approved or authorized by the PCP or non-emergency care isn’t approved, the patient will be held responsible for the payment in full of any services that are rendered (HMOs, PPO, & POS Plans, 2019).
There are also some hospitals that don’t accept reimbursements from patients that have health insurance coverage that doesn’t reimburse them enough unless it’s in an emergency (Torrey, 2018).
Reimbursements for post-acute treatments and services has been remaining to be a work in progress for two reasons. The first is because of the tight deadlines that wasn’t allowing adequate time on developing the systems with many of them exhibiting improper imperfections (Newhouse, 2005). The inpatient hospitals prospective payment system (PPS) had been underdeveloped for more than a decade and a form of this was already used by some states before it had been introduced into Medicare.
The second reason is in the architecture of the separate payment systems for each type of post-acute provider. Many of these types of patients can be potentially served by many types of providers (Newhouse, 2005). For example, a patient that has had a stroke can get physical or speech therapy in a rehabilitation hospital, hospital outpatient department, skilled nursing facility, or at home with a home health agency. But these payment systems are not all neutral among these sites because the reimbursements for the same patient that is receiving the same services at different sites can be different. Rehabilitation and skilled nursing facilities are paid per day and the home health agencies are paid per 60-day episodes (Newhouse, 2005). Generally, the short-stay patients will be in a rehabilitation facility and long-stay patients will be in a skilled nursing facility. Each facility has a function of payment based on the average cost of patients that are in that type of facility. The average cost will substantially vary based on the characteristics of the patients and the intensity of treatments will also vary because of the rehabilitation centers will generally provide more intense treatments while having the highest reimbursement rates (Newhouse, 2005).
