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Healthcare Recommendations of Payer Mix Payments

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If You Were in Charge

As a health services manager with expert knowledge of managed care systems, insurance, and regulations, develop a payer mix goal with objective referenced rationale based on utilization management for a healthcare organization of your choice (real or hypothetical).
The payer mix should:
• Be reported regarding percentages for each patient group receiving services at your specified organization
• Include pros and cons associated with your recommendation to address the recent loss in A/R (money coming in) based on the payer mix payment
• Be based on a list of 10 common services and corresponding payment structures (e.g., make one recommendation if your payer mix payment dropped 20 percent in one-quarter)

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Solution Summary

The expert examines healthcare recommendation of payer mix payments. Ten common services and corresponding payment structures are determined.

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As a health services manager with expert knowledge of managed care systems, insurance, and regulations, develop a payer mix goal with objective referenced rationale based on utilization management for a healthcare organization of your choice (real or hypothetical).
The payer mix should:

I will provide a general overview of the payer mix that is used by the five main hospitals in the state of California. This will be predicated upon the research that has been conducted by the academic expert and should only be used as a guide by you to allow you to formulate (your) own payer mix model. In reference to the hospitals in the state of California, they are in alignment with most hospitals in the country wherein these hospitals average approximately 45% of their payments from Medicare. On average, Medicaid represents 14% of the payment mix for most United States' hospitals. Private health insurance as well as other out-of-pocket payents comprise the remaining 40% of the remaining payment mix for the majority of U.S. hospitals.

• Be reported regarding percentages for each patient group receiving services at your specified organization

The five largest hospital chains that were used for this summary and most importantly use the aforementioned payment mix are HCA Holdings, Tenet Healthcare, Community Health Systems, ...

Solution provided by:
Stephen Washington, MS
Education
  • BS, Sam Houston State University, 1903 University Avenue, Huntsville, Tx 77340
  • MS, Prairie View A&M University
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