Causes of High Hospital Reimbursement Denials

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TABLE OF CONTENTS

REVIEW OF THE LITERATURE1

Introduction1

Health Care Reimbursement System1

Health care Costs and Reimbursement3

Evaluating the Effectiveness of Nurse Case Managers in Improving Health Outcomes4

Nursing Care Case Mix in Hospital Reimbursement5

High Reimbursement Denials in Hospitals6

REFERENCES8

REVIEW OF THE LITERATURE

The relevant topic of the research and the year of publication are criteria to choose the suitable topic. This section provides an in-depth and critical evaluation of the previous researches. It gives a synopsis and a summary of the factors due to which there are high reimbursement denials.

Introduction

The rate of hospitalizations and readmissions shortly after hospitalization continues to be problematic. Health care costs are rising in the United States. The Balanced Budget Act (BBA) of 1997 mandated that reimbursement for patient care services be determined on a prospective basis rather than on a fee-for-service basis. Prospective payment identifies a fixed fee, predetermined by the payer that is expected to cover the costs for care and treatment, in contrast to a fee-for-service payment system, used historically, where each treatment, procedure, or care was billed as individual items on an itemized bill (Lloyd, 2002).

Health Care Reimbursement System

Initially, when managed care was implemented costs did decline; however, managed care has not delivered the long-term benefit of cost containment promised at its inception. In the last decade, significant changes have been made in the reimbursement policies on a local, state, and national level. These changes have affected individuals, organizations, and society as a whole. Because of the changes in health care reimbursement and increasing costs, there is a need to redefine nursing roles and care delivery systems. The care management specialty of health care has been created, in large part, because of the influence of managed care, third-party payer, and reimbursement systems (Meek and Adams, 1999).

Health care delivery models are also changing as the supply of nurses' decreases and new roles are being created to complete tasks and functions once performed by RNs. The ability to effectively and successfully lead and manage health care organizations is being hampered by the historical and traditional strategies of care delivery and organizational management (Krumholz and Chen, 2000).

Changes in health care organizations often mirror societal change and are influenced by shared experiences, values, norms, perceptions, role definition, leadership, economics, and political pressures in a given time. For this reason, examination of role functions, data trends including measures of hospital efficiency and effectiveness, and communication patterns within a social context provides a framework to learn from the past to create new and effective paradigms to support changes in health care delivery models (Felker and Califf, 2004).

In order for health care organizations to function successfully, health care delivery models will be required to change. The creation and development of new health care delivery patterns and roles, and the identification of communication patterns, documentation, collaborative outcomes, and measurements of effectiveness will be required for clinical and financial success in health care organizations of the future. To do this effectively, a greater understanding of organization culture, professional roles and relationships, and ...