732.2.1: Reimbursement Methodologies ? The graduate describes and compares contemporary
healthcare reimbursement methodologies and systems utilized in the United States.
732.2.3: Voluntary Healthcare Insurance Plans and Managed Care ? The graduate describes key
components of private, commercial, and Blue Cross and Blue Shield insurance plans and evaluates how
various insurers use coding in the billing process.
732.2.4: Government-Sponsored Healthcare Programs?Including Medicare and Medicaid ? The
graduate evaluates and explains various government-sponsored healthcare programs and recognizes the
impact that government-sponsored healthcare programs have on the healthcare system in the United
732.2.5: Government-Sponsored Healthcare Programs?Other Components and Methods ? The
graduate evaluates and explains components and methods of non-Medicare/non-Medicaid governmentsponsored
healthcare programs; and recognizes the impact that government-sponsored healthcare
programs have on the healthcare system in the United States.
732.2.6: Ambulatory Reimbursement Systems ? The graduate evaluates and explains the structures
and components of and performs payment calculations for outpatient healthcare reimbursement in
The healthcare reimbursement systems in the United States are complex. A health informatics professional
needs an understanding of the basic principles of the third-party payer system and the many options that
are available to citizens through government-funded healthcare programs. Private and commercial
insurance companies and BlueCross BlueShield plans offer a different menu of options to their clients. All
third-party payers are interested in decreasing healthcare costs while improving quality and controlling
access to unneeded services.
In this task, you will examine the complexity of the healthcare reimbursement systems and begin to
compare the similarities and differences between them. To complete this task, write an essay discussing
each type of healthcare insurance plan listed, as well as the plan components, reimbursement provisions,
restrictions, and the impact government regulations have on each.
Write an essay in which you do the following:
A. Discuss the insurance plan components and restrictions of each of the following:
1. Fee for service (indemnity) plans
2. Managed care plans
3. Government-sponsored health plans
? State Children?s Health Insurance Program (SCHIP)
? Indian Health Service
4. High-deductible health plans/healthcare savings accounts
B. Discuss the inpatient and outpatient reimbursement process of each of the following: