Overview: Healthcare Portability In The Health Care Industry

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Register to read the introduction… In business, the recipient of the product or service sold is the payer, and the one setting the price is the seller. In health care, the majority of payment is made through a third party, and the rates are predetermined mostly by the payer. Only self-pay patients are charged the price set by the health care institution. However, because there is a high possibility of non-payment due to the high cost of medical/health care, discounts are often offered to avoid loss due to bad debts. In a regular business setting, satisfactory condition of the goods received and services rendered is enough basis to warrant payment. While in health care, payers require proof the service rendered is necessary, properly executed and in some cases, must have prior authorization. Concurrent and retrospective reviews are also conducted by the payer’s representative to satisfy the necessitation and intensity of service rendered. While in a regular business setting, buyers have the obligation to pay, in health care, the payer is always looking for ways not to pay, at times due to simple technicalities. Denials of payment may occur and opportunities for appeal abound. This proves to be costly and time consuming for the service provider. To make sure this does not happen, the healthcare facilities have to undergo procedural measures and constant …show more content…
In many cases, the rates are below cost. Facilities often times resort to cost shifting to make up the losses. This leads to inflated charges and self-pay patients are often the hardest hit. Many facilities do not accept Medicaid for this reason. Private payers still have predetermined rates, but because of competition in the insurance market, they do not follow government practice of pricing below cost. However, they can have similarly strict compliance requirements, including technical prerequisites like claim procedures.

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