Essay Sample: Analyzing and Discussing the Payer Mix for APN Release

The health care system has since been preparing to reach the community in every possible way. To create a good public image and relations it is important to reach the immediate community (Thomas, Garg, & Vallat, 2017). As an organization that operates in health care system, there will not be any better way than to reach the community through nursing. Advanced Practice Nurses (APNs) can provide better care for the vulnerable and all people in the community. For the organization to decide to hire them is something that will be positive and beneficial. The APNs have to be prepared to meet a variety of patients. However reimbursement of the nurses to the community will not be easy with relation to the payer mix (Iliff, Patel, Nilgiri, & Upshaw, 2017). There are three realities concerned with the payer mix which the organization has to consider before releasing nurses to the field for the same. The three aspects of the reality are that in the community the APNs will be dealing with cases of uninsured individuals, those with private insurance and those insured by the government (public insurance of Medicare).

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It is very important for the organization to understand their payer mix. Understanding the payer mix helps the organization plan and understands the cash flow that will arise due to the implementation of the community program.

To begin with, reimbursement of this kind can be referred to as third party reimbursement. Third-party reimbursements require a lot of legal issues especially on the part of payer mix. It requires quite a complex structure (Pruitt, 2015). It involves regulatory factors that have to be taken care of both at the national level and at the state level. Different states have different regulating terms of the APNs. All of the rules vary from payer to payer. All the billing rules depend on the payer and the type of care or medical service provided to one. A lot of insurers always follow the public Medicare guidelines in order to remain on the safe side of the law. However, the organization is alive to the fact that each of the insuring agencies regulates payer and reimbursement in their own unique way in accordance with the law.

The organization has to be aware of the way payment is done for each insurer. An APN nurse is allowed to bill for under-recognized patient who does not have insurance services at all. The rule lying rule is that the nurse will pay for the patient using his National Provide identifier (NPI). The NPI is a unique code given by the national government (Rowley, Phillips, O'Dell, El Husseini, Carpino & Hartman, 2016). It is unique to every nurse. The organization will allow any nurse who is willing to pay for anyone in the community who doesn't have any insurance cover services. The NPI billing services apply even for those nurses that are under a private insurer but are willing to go the extra mile. The unique code remains constant and will be used for the same purpose too. The nurse should be checked if they meet the state's licensing processes. The state licensing process is unique to every federal state. The nurse should have met the licensing process of the state that they are planning to deliver the service. With this matter, the organization should ensure that they involve those APNs with valid license to ensure Medicare processes and credentialing processes is done in accordance with insurance laws.

An important factor to consider is the demographic of the kind of patient that the nurses are going to meet. The demographic measure of patient is very important when dealing with patients that receive private insurance covers (Antognoli, Seeholzer, Gullett, Jackson, Smith & Flocke, 2017). For public insurance cover, the money will be reimbursed to the organization making it easier to pay the disbursed APNs to the community. However, payment disbursed through the public means take quite sometimes. It takes longer than the one disbursed through private means (Antognoli et al., 2017). However, in the case of private insurance, some patients might refuse to pay the nurse in cash even after being reimbursed by the insuring company (Antognoli et al., 2017). These patients who seem not to be comfortable paying for the services out of their pocket despite being paid by the private insurance company might be difficult to deal with. It explains why the organization should consider a demographic check on the patients.

An additional aspect to consider is the particular rules that the private insurances offer. Some private companies only provide payment when their patients are given services by particular medical organizations. These insurance are only willing to provide insurance to particular referrals.

Another factor to consider is the level of network and relationship that the organization shares with insuring corporate (Khanna, Shaya, Chirikov, Sharp, & Steffen, 2016). Strong networking relationships will enable some of the communal patients to receive the care they have always needed. It can be made possible when the organization strikes a deal with one of the insuring agencies. The insurance agencies can sponsor the whole community outreach program. When the organization finds another with like principles, it will be easier to create a payment plan for the APNs once there is a sponsorship program.

For the organization to optimize the payer mix there is a crucial need to realize success in the community outreach program that will be headed by the APNs. The community practice can be conducted by the organization without necessarily focusing on the insurance plans and payer mix (Lewis, Kutzner, Biskup, & Gupta, 2015). The organization should consider engaging inside financial operations that can boost revenue for the program. A boost in revenue will ensure operational efficiency even without really involving insurance programs and their payer mix. It would be a perfect proposal to consider implementing the lean business principle. This way, if any of the three payers mixes is not efficient enough the company will still find ways of going on with the community outreach plan.

In conclusion, it is important for the organization to realize that all the payer mix and the insurance plans are important. There isn't one size fits its all-payer mix which explains why focusing on the mentioned factors is important. Some of the factors to consider as mentioned in this essay include; the laws and regulations of the federal and state government, the rules of different private firms and the demography of the target population. After accepting that there isn't one size fits it all assumption, the organization should consider monitoring the frequently changing numbers. Care should be taken by the organization so that they do not burden the APNs that will be sent to the field. Some nurses might not have the insurance plan that fits the patient they meet out in the fields especially if the patients have no insurance at all. Provision of a slippery slope might be exceptionally risky for the organization, the APNs and might be a cause of failure for the program. Optimization of all the payer mix is absolutely crucial to the success of the chosen nursing practice.

References

Antognoli, E. L., Seeholzer, E. L., Gullett, H., Jackson, B., Smith, S., & Flocke, S. A. (2017). Primary care resident training for obesity, nutrition, and physical activity counseling: a mixed-methods study. Health promotion practice, 18(5), 672-680.

Iliff, D. C., Patel, P. S., Nilgiri, P., & Upshaw, S. S. (2017). U.S. Patent Application No. 15/288,578.

Khanna, N., Shaya, F. T., Chirikov, V. V., Sharp, D., & Steffen, B. (2016). Impact of case-mix severity on quality improvement in a patient-centered medical home (PCMH) in the Maryland multi-payor program. The Journal of the American Board of Family Medicine, 29(1), 116-125.

Lewis, P., Kutzner, E., Biskup, N., & Gupta, S. (2015). The impact of the Affordable Care Act on payor mix in an academic plastic surgery center. Plastic and Reconstructive Surgery, 135(4S), 1195.

Pruitt, Z. (2015). Jonas and Kovner's Health Care Delivery in the United States, 11th.

Rowley, R. A., Phillips, L. E., O'Dell, L., El Husseini, R., Carpino, S., & Hartman, S. (2016). Group prenatal care: a financial perspective. Maternal and child health journal, 20(1), 1-10.

Thomas, A., Garg, S., & Vallat, S. (2017). U.S. Patent No. 9,547,960. Washington, DC: U.S. Patent and Trademark Office.