Case Study: You are assessing the payer–patient mix for a health care organization. Currently, your payer mix is 40% Medicare, 10% Medicaid, 25% traditional indemnity insurance, 20% managed care, and 5% self-pay patients. Complete the following:
Using the most common office visit, CPT code 99214, determine the reimbursement from the Centers for Medicare and Medicaid Services (online fee schedule available for Medicare).
Using the same CPT code, 99214, determine the be possible to obtain actual reimbursement information from your personal insurance carrier. If the information is not available, assume reimbursement by traditional indemnity insurance is usually 200% reimbursed more than Medicare and Medicaid, and managed care is usually 133% more than Medicare and Medicaid.
Compose an accounts receivable benchmark from this information showing columns for current, 30–60, 61–90, 90–120, and greater than 120 days.
Assess the information for areas of improved reimbursement of at least 20% or more.
Evaluate the options available to change the payer–patient mix with consideration of related legal and ethical issues.
Propose a best strategy with justification and rationale based on effective decision-making tenets.
Spreadsheets demonstrating the accounts receivable analysis will be attached as appendices, and there will be at least 7 relevant peer-reviewed academic or professional references published within the past 5 years. Also attach appropriate fee schedules.
