Healthcare Reimbursement and Utilization Management

Running head: HEALTHCARE REIMBURSEMENT AND UTILIZATION 1
Healthcare Reimbursement and Utilization Management
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HEALTHCARE REIMBURSEMENT AND UTILIZATION
2
Healthcare Reimbursement and Utilization Management
Accountable care organizations are made up of several providers who are centred on
dealing with patients, the population and are responsible for providing services from
suppliers that who are covered by Medicare (Zelman, McCue, Glick & Thomas, 2014).
Healthcare reimbursements and utilization management are methods used by providers to help
manage the cost of healthcare. These providers determine the urgency and importance of a
service before a service is provided. It helps minimize hospitalizations and other procedures
that are not necessary (Centres for Medicare and Medicaid Services, 2017). Moreover, ACOs
identify problems, claims and provide care. The other methods of utilization management
include; reducing costs of specialists and providing financial incentives.
Strategies for reimbursement and utilization management
This scenario aims at investing in assistants physicians and also in primary care
physicians. The ACO aims at improving and coordinating the health conditions of individuals
who have chronic diseases (Centres for Medicare and Medicaid Services, 2017). There are
few models for reimbursement that cover this scenario. According to Zelman et al, (2014)
global capitalization is a reimbursement model that should be introduced in this scenario.
Global participation is payment model which reimburses the provider with a specific amount
as per their capita income according to the services provided (Centres for Medicare and
Medicaid Services, 2017). In addition, this model ensures that patients with chronic diseases
receive better preventive measures and care management. Therefore, global capitalization
uses specialists and primary care providers to enable patients to stop the progress of such
chronic diseases at an early stage.