Healthcare Policy

Explain the flow of funds within an organization including private pay and third party reimbursement

The flow of funds refers to a system of accounts which is used to monitor how the money flows and how it is used within the organization. Some people purchase the health insurance cover for themselves. Others are paid for by their employers. The medical insurance covers are meant to cover the health of the consumers whose premiums are paid. For an organization to succeed, the flow of money has to be well accounted for in order to avoid the cases of frauds and embezzlement of funds. The organization tracks and analyzes the accounts and the findings are provided after a certain period of time (Paolucci, 2011). The accounts are used to indicate the performance of the organization in terms of profit generation. The data enumerated from the accounts is normally compared to the prior data in order to assess the financial strength of the firm at a certain period of time and assess its future performance possibility.
 How can you prevent abuses and inefficiencies in third party payments?

Most firms including the healthcare sector depend on the third-party administrators to manage their spending in healthcare. However, abuse and fraud may arise in most cases concerning the management of the funds. If fraud is efficiently managed, it will ensure that the health plan is improved. In order to prevent fraud and abuses in the third payments, various strategies need to be put in place.  Firstly, it is important to pay very keen attention to the payment integrity issues. This regards ensuring that the correct payment is made for the right client and for the correct services and to the correct service provider. The managerial contract should protect the interests of the employers. In order to prevent the abuses, the billing should be changed and the measures be put to detect the major coding early enough. This will help in speeding up the conversations between the service providers and the payers in order to assess what causes the differences in the normal billing. Open dialogues and the transparency among the relevant parties should be considered as they help to bring the problems on the surface and lead to a greater understanding of the root cause (Paolucci, 2011). Eventually, this will lead to improvement in the quality of healthcare.

The data collection should be centralized in order to monitor the operations. The collection of data plays an important role in preventing abuse.  The relevant data sources should be identified and compiled. Such data may include the information about the applicants and the beneficiaries. This assembled data enables the system to acquire the relevant information which is helpful in making the right decisions concerning the applications, the incoming claims and any other transactions through risk-scoring.

The management should create a learning system which responds to the threats which keep on changing. Continuous practice in fraud prevention leads to a permanent impulsiveness which plays best as a defense against the fraudsters. This is aimed at modifying the defenses rapidly so that the antagonists play a catch-up continually. The changing of the systems ensures that the fraudsters’ costs increase hence cutting down the firm’s costs. It is important to measure the efficiency of each action taken by the firms’ systems and then make adjustments based on the results.

The organization should also emphasize on the prevention in order to get the best returns on determinations. If a firm insists on implementing the prevention mechanisms, the costs of overpayments and those of the chase are reduced.  This also scares away the potential fraudsters since they become aware that their behavior is being monitored. The firm should share intelligence in order to reduce the frauds which are intentional (Alper, 2017).  The firms should implement the use of a collective intelligence in order to extend the analytical reach such that the systems can screen and share any instances of abuse or fraud across the entire network. This is based on the fact that many people who are working together tend to be more effective than one or two people working alone however intelligent or capable they may be.
Briefly define the flow of funds in the Care Organization.

For the success of a health organization, a good flow of funds framework should be created. The flow of funds entails the accountability of how the consumers are to be treated, the cost of drugs and the payable premiums thereof. The health insurance for the employees is normally paid by the employers in lieu of bonus wages. The premiums are received by the employee tax-free.
 What challenges do consumers face who are enrolled in private insurance?

            Most consumers have reported to experience difficulty in paying their premiums. This may be due to high rates of premiums charged by these insurance firms. Although the insurance firms continue to offer subsidies in order to lower the cost of coverage, many people still have challenges in affording the premiums and the out-of-pocket costs that are involved in accessing the care. Some people have low incomes and live below poverty line. Some people also have other needs such as providing food, housing, and education for their children which straintheir budgets leading to a difficult balancing between catering for the family necessities and the insurance premiums. Others may experience quite good health for a long time and paying the money they do not use regularly becomes a challenge. They view this as paying money just to for the benefit of other people apart from themselves. Some insurance firms have complicated procedures involved in processing the amounts to cater for the consumers’ medical care. This may sometimes necessitate the consumers to pay extra money in hospitals for medication whenever a need arises. This happens especially when emergency cases are involved due to the delay caused by the long procedures involved.
What methods can you use to empower the consumer?

Offering incentives to the consumers can be of great importance. This includes reducing the number of premiums paid based on age, health status or generally.  The consumers should also be able to access the relevant information regarding the insurance policies.  Consumers do pay their premiums or they are paid for by their employers. This makes it necessary for them to have a say in where and how their money is spent. Transparency is, therefore, necessary in order to assure the consumers that their money is well utilized and can be accounted for (Meyers, 2010). A website should be simplified which will enhance the transparency about the prices of the drugs covered. The insurance firms should also simplify the procedures involved in medical cover and implement new tools which are capable of showing the consumers the plans which include their doctors.  The administration should put more efforts in promoting the in-person support during the plan selection and sign-ups by the consumers in order to provide and explain the insurance policies in a deep manner and help them in making the best decisions.


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Health Literacy and Health Insurance Literacy: How to Move Forward (Workshop), Alper, J., &

            National Academies of Sciences, Engineering, and Medicine (U.S.). (2017). Health

            insurance and insights from health literacy: Helping consumers understand :

proceedings of a workshop. Press.Bottom of Form

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Meyers, S. K. (2010). Community practice in occupational therapy: A guide to serving the

            community. Sudbury, Mass: Jones and Bartlett Publishers. Press.

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Paolucci, F. (2011). Health care financing and insurance: Options for design. Berlin: Springer.


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