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Payment Systems

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Submitted By makaylalynn3
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There are many complex processes involved in the health care organization’s payment system. There are numerous agencies such as State and Federal agencies a health care organization is accountable to. The guidelines the health care organization is required to follow are strict and if the health care organization does not follow the rules and regulations the governing agency can withhold payment.
I will use the hospital as an example. In the United States hospitals are obligated to assist patients that arrive at their Emergency Room whether they have the financial funds to pay for their health care needs or not. For those that visit the Emergency Room that have health insurance this in itself is a complex issue. There are numerous health insurance organizations and many of them have their own individual set of rules and regulations the contracting agency is responsible for following. A few examples of the stipulations of insurance organizations are the different deductibles that have to be met; some pay for certain tests but not all tests; some pay for various procedures and some don’t, and some cover pregnancies and children and some don’t. When an individual has a governmental health insurance plan usually the plan is non-negotiable and covers certain conditions at certain cost levels. For instance a patient goes to the hospital with a diagnosis of a CVA the insurance organization will reimburse them for the CVA but they will not cover any other condition. This is commonly seen regarding residents that are admitted from a nursing facility to a hospital. They will be admitted for one condition and the hospital will treat them for that condition only. Usually the elderly patients have numerous other diagnosis that require treatment but due to the stringent rules and regulations imposed on the hospital systems the patient does not receive the care they need. There is

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