Can someone help me with these 7 questions??
Medical groups are often paid on a fee-schedule nmental pro- receiv basis, with limited capitation arrangements sometimes grams and rising levels of uninsured patients, many healthcare firms have prices that are multiples of cost 2. [(200 being used. The fee schedules are usually by current but profit levels are only marginal. Health plan con. the t procedural terminology (CPT) and, in some cases, are mi Two directly related to Medicare's resource-based relative tract negotiation can be a primary means to profit paym profi value scale (RBRVS) payment system. The health plan enhancement if reasonable rates of payment can be rem often contracts to pay some percentage, for example, negotiated. It is also important, however, to examine Larg 1 10% of Medicare RBRVS rates. A sample schedule of specific contract language because reasonable pay. 4. ment rates mean very little if significant numbers of insu fees for a medical group is presented in TABLE 6-5. claims are denied. now avo Wit oth ASSIGNMENTS Thi the 1. You have been asked to comment on the reasonableness of a healthcare firm's prices using the ROI methodology ho described in this chapter. Your review has determined that the firm's costs are in line with industry averages and its overall investment is similar to other comparable healthcare firms, but its level of return on investment is 20% higher than industry averages. Are there any factors that the firm might be able to use to justify its higher-than- average rate of profitability? 2. You are trying to determine the average discount rate on charge payers to be used in the formula described in Figure 6-3. You have the following three payers with different discount rates: 200 uninsured patients who pay on average 5% of charges, 300 health plan patients who pay 85% of billed charges, and another block of 500 health plan patients who pay 75% of billed charges. What is the average discount rate that should be used in Figure 6-3? . Quality is usually described as a key factor in pricing. How can a healthcare firm with perceived higher levels of quality of care benefit from higher quality if 75% of its business is derived from Medicare and Medicaid patients who pay on a fixed-fee basis that does not adjust for quality differences? Consumer-driven health plans often rely on large deductibles that are often funded via a health savings account framework. How might the presence of a large deductible affect price elasticity for health services? 5. In negotiating a health plan contract, why is it important to spell out precisely what constitutes a clean claim? 6. Your hospital has a contract with a large national health insurer that barely covers cost but does provide a small overall profit. Under the terms of this contract, the insurer may extend its contract terms to other plans when it. leases its network to them. Why might it be desirable to remove this provision from your contract? 7. Using the example of Table 6-2, assume that the average cost has jumped from $100 to $105. All other factors in the example will remain the same. What will be the new required price
