Question

Why is it important to make the distinction between provider payment and provider reimbursement? Discuss the distinctions using examples of provider reimbursement.

Answer 1

The transitional form of provider payment comprised of the patient visiting the hospital , once care is provided ,the hospital submits a claim to the payer; the payer pays for the claim reimbursement. When the information provided in the claim is inaccurate / missing that might be delay in payment or a deny of payment which is an inconvinence to the provider. There may be cases where expenses cannot be recovered
Hence there is a need of predefined Provider reimbursement models

Various Provider Reimbursement Models:
Fee-for-service:
The health plan pays the provider an amount based on each type of service provided by the provider

Discount:
When a provider sends the health plan/patient a bill, there is a predefined reduced rate on behalf of the members. Payment is made is a predetermined percentage of the total bill for services provided

Salary
Providers are paid a salary based on their performance in areas like quality of care and patient satisfaction

Basis of the diagnosis:
Providers are paid a set fee to treat certain kinds of medical conditions

Per diem
Providers/hospitals are paid a set fee for the of days the patient used their service