The organizational structure of medical care in the United States is characterized by a decentralized healthcare management system with a division of powers between the federal center and the states. The US Department of Health and Human Services (HHS) is represented as the federal executive body which implements and controls 330 social and health programs through 27 divisions (Shrank et al. 1505). In particular, it oversees such programs as Medicare (health insurance for the elderly and disabled) and Medicaid (health insurance for people with low incomes). Having relative independence, the US health policy has a strong impact on the economic sphere of society and provides for comprehensive control by the authorities of the entire system of medical care.
Aetna/CVS Health, Anthem, Centene, Molina, and UnitedHealthcare are the five biggest health care businesses in the Medicaid managed care market. As of September 2020, states have contracted with 281 Medicaid MCOs, 112 of which were controlled by only five businesses. Each firm has operations in more than a dozen states. Parent company data suggests that by the end of 2020, these MCOs were providing essential healthcare to more than 35 million Medicaid recipients. Companies don’t break out their membership numbers by age range, but if they enroll children at the same rate that they enroll adults in Medicaid, then these MCOs cover 14 million kids.
Aetna, a subsidiary of CVS Health, serves as a trusted advisor for health care and financial planning for about 39 million individuals. Aetna, one of the largest and most diverse health care benefit providers in the United States, offers its customers access to a wealth of information and tools to help them better manage their health and their health care costs. CVS Health has been providing health services to communities, online, and in people’s homes for many years. CVS Health retail clinics provide urgent care on an as-needed basis, while our clinical programs for chronic diseases and weight problems provide specialized treatment for certain patient populations. Some of the most complicated medical demands may also be met by the services they offer: care provided in the comfort of one’s own home by trained medical professionals.
There are four parts of Medicare: Part A which provides inpatient/hospital coverage, Part B provides outpatient/medical coverage, Part C offers an alternate way to receive Medicare benefits, and Part D provides prescription drug coverage. Various trends influence the healthcare business. In addition to government legislation, technology is altering the delivery of healthcare services, and MayoClinic must be prepared to adapt. Other developments include the national health people 2030 directive, which has diverse effects on healthcare workers.
In every medical practice, patient engagement is of utmost importance due to the correlation between high engagement levels and improved reimbursement. Patient participation may inform patient and provider education and policy, as well as improve care delivery and administration.
The alignment of workflow and information life cycle is essential for staff productivity. Developing a solid alignment may be crucial for one simple reason: if the IT agenda is defined improperly or just partly correctly, considerable organizational resources may be wasted; they will not be used to advance strategically vital areas.
Millions of Medicare seniors face major health and mental health difficulties nationwide. The beneficiary population is growing fast, undergoing demographic shifts, and dealing with difficulties including functional limits, various chronic diseases, social isolation, economic instability, and ageism.
The typical processes of RCM medical billing are shifting in response to the nation’s growing policies aimed at expanding access to healthcare and closing the health equity gap. AHIP (America’s Health Insurance Plans) has expressed support for the CMS’s proposed modifications. It suggests that there may be more significant adjustments in premium costs and an expansion of covered services. In addition to improvements in patient financial services, the RCM medical billing ecosystem may experience beneficial changes as a result.
Various payment schemes with varied degrees of efficiency have been employed for healthcare reimbursement. Whether these methods are used individually or in combination, it is essential that the resultant systems compensate according to the amount, complexity, and quality of care delivered.
Works Cited
Shrank, William H., et al. “Waste in the US Health Care System.” JAMA, vol. 322, no. 15, American Medical Association (AMA), 2019, pp. 1501-1507. Web.