For medical professionals and institutions, the importance of reimbursement in healthcare cannot be overstated: this is how they are paid, of course, and how they are able to continue providing services to consumers. But, as folks on both sides of the equation know, healthcare is far from simple, and neither medical decision-making nor healthcare reimbursement rates are simple—they are continually being reformed.
Ideally, healthcare providers would be able to make course-of-treatment decisions for their patients through patient symptoms, diagnosis, open discussions, and insight gleaned from the patient's medical history. In other words, in an ideal world, consideration of how providers will be paid would not hinder physicians from making the soundest medical directives for the patient. However, we do not live in an ideal world, and complications in healthcare reimbursement often interfere with what may be the best course of treatment for particular patients. This is an important consideration for medical professionals, administrators, and lawmakers. However, a new trend is emerging: doctors who don't take health insurance. These providers have opted to take cash payments, set up payments plans, or offer a monthly subscription. A growing number of doctors simply are not taking contracts with insurance companies, although the concentration varies by region and by specialty. That leaves patients to pay the market rate the doctor charges, and then submit a receipt to get reimbursement for out-of-network coverage, if they have it (1).
What are the ethical implications associated with each model? If you were the business office manager of a small practice, which payment model would you prefer and why?
Be sure to respond to at least one of your classmates' posts.
Full Answer Section
Direct Payment Model
- Potential for Price Gouging: Without the regulation of insurance companies, providers may charge excessive fees, particularly for patients who are unable to negotiate.
- Limited Access: Patients who are unable to pay upfront may be denied care, even if they have insurance coverage.
Ethical Considerations for Business Office Managers
As a business office manager, I would prefer a hybrid model that combines elements of fee-for-service and direct payment. This model could involve a base fee for services, with additional charges for certain procedures or medications. Patients could then choose to pay out-of-pocket or submit a claim to their insurance provider.
This hybrid model offers several advantages:
- Flexibility: It allows for flexibility in pricing and payment options.
- Improved Access: Patients with limited financial resources may still be able to access care by paying a portion of the cost upfront.
- Reduced Administrative Burden: By reducing reliance on insurance reimbursement, the practice can streamline its billing processes and reduce administrative costs.
However, it is essential to ensure that the pricing structure is transparent and fair, and that patients are informed of their options. Additionally, the practice should have policies in place to assist patients who are unable to afford care.
Responding to Classmate's Post
[Insert classmate's name] raises an important point about the potential for discrimination based on socioeconomic status in a direct payment model. It is crucial to ensure that pricing policies are equitable and do not disproportionately burden low-income patients. One way to address this is to offer sliding scale fees or payment plans based on income. Additionally, the practice can partner with community organizations or government programs to provide financial assistance to patients in need.
By carefully considering the ethical implications of different reimbursement models, healthcare providers can strive to provide high-quality care that is accessible to all patients.