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Case managers are important in the provision of health care to individuals. They act as important links between consumers and service providers. Their functions are essential in streamlining the service delivery to customers. Their vast knowledge of the providers and consumers is an asset to both insurance providers and consumers (Giunta & Cain, 2015). Case managers are well versed with the user needs and conditions as well as they know the right service provider who matches the need of the customer. It becomes increasingly easier for both the consumers and service providers to operate and receive the right service. Care managers are drawn from various specializations such as nursing and psychiatrists among other qualified individuals. The major drive for case management is the provision of right treatment to the consumers (Swanke & Zeman, 2011). They link the consumers with the right service provider and ensure the right treatment is offered. This paper will examine how case managers help in maximizing reimbursement and describe the differences between the government-funded programs and the private sector.
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Dealing with health service consumers is a complex function. Clear knowledge and understanding are inevitable. Care managers have an extensive knowledge of healthcare service providers and the conditions of the consumers. They are important connections between the consumers and service providers. They use the available information to connect the consumers with the right care providers. Most of the complex cases in the USA include people with substance abuse problems, people with emergency cases and care for the elderly (Giunta & Cain, 2015). Most covers are offered to these groups of individuals by the government programs or private insurers. The groups are also complex and they need specialized care to ensure their well-being. Most of the reimbursement is made to providers by the relative insurer. The providers include the Medicare and Medicaid programs and a host of various private insurance providers (Swanke & Zeman, 2011). There are increased cases of auditing by the providers to establish the authenticity of claims made by service providers. Some providers have lost cash in the process as the result of wrong admissions.
Many hospitals fail to utilize their full potential through wrong admissions. The hospital beds are occupied by the patients that do not necessarily need admission, hence limiting the hospitals’ capacity to help those who require this admission. This act limits their incomes, and the insurers fail to reimburse them as the result of wrong admissions. Care mangers have a critical role of advising the hospitals on who needs to be admitted and who needs outpatient services. The care managers have the information about the patients and the treatment that they require (Moreo, Moreo, Urbano, Weeks, & Greene, 2014). Thus, they advise the hospitals on what care a patient needs. Hospitals cannot lose cash in the form of reimbursement from insurers. The care managers are the direct links of the consumers, helping the consumers take covers that suit their needs. This information is helpful to both the consumer and the service provider. The service provider will offer the service that the care manager prescribed for the consumer. Hospitals benefit from taking advantage of serving both the inpatient and outpatient clients effectively. The hospitals receive the accurate reimbursement and they will not suffer from penalties due to irregular admissions.
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With sound knowledge of the consumer needs, hospitals provide the right care. The consumers’ conditions will be treated effectively and patients will be assured of their well-being. The successful treatment of the consumers ensures that the hospitals can claim reimbursement from the insurers as insurance companies fail to reimburse service providers in case the consumer is not treated successfully (Moreo et al., 2014). The hospitals lose income even after service provision. Thus, the care managers are a solution to the problem. They refer the consumers to the right hospitals where they can get the right treatment. The knowledge of the services that different players offer enables them to refer consumers to only places where they can get right service that befits them. Care mangers can prevent unsuccessful treatments and lack of reimbursement to service providers. The care managers conduct monitoring exercises of the consumer planned care program. The exercise enables them to respond to any changes in the consumer conditions. They can advise the care providers on the changes in program or they even advise to change the provider. The changing nature of consumer health needs at some points can increase the service provision costs. The care manager will assist in the recovery of the excess amount from the insurers.
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Care managers are the right intervention for the health care insurance services. The number of individuals in need of treatment is on the rise. On the other hand, the budgets to cater for the rising number of cases are constrained. Research has shown that older people that receive the services of the community-based care are less likely to be hospitalized. The service of care managers reduces the frequency of the insurance companies to offer reimbursement to the service providers. Care managers ensure that the limited resources available for the insurance provision are used to take care of the right cases (Swanke & Zeman, 2011). Hospitals are also to benefit by ensuring that they use their resources prudently and the recoup of funds by the insurance companies will be avoided.
The Government-Funded Program and Private Sector
The government-funded programs target a certain group of individuals. Some of the targeted groups include the older people and sometimes Native Americans. The funding targets homebound people aged above 65 years. This group requires particular treatment to enjoy a longer life span. The country has different departments such as the Area Agency on Aging, department of aging across the states. The departments fund various programs that are aimed at improving the welfare of the older people. The agencies recruit care managers to implement various services to the homebound aged group of people within distinct areas of interests. The federal government provides funds that are distributed to the states for the purpose of medical support of the groups in need of help. Medicaid health care program is a medical fund of the federal government to the states. The states are responsible for the utilization of the funds in supporting the health care of the older people (Moreo et al., 2014). The government-funded healthcare programs are selective in that they target a certain group of individuals.
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In the government-funded programs, the care managers have the role of reducing the number of visits to the service providers or the cases of hospitalization. Consequently, the care management programs aim at reducing the number of the patients accessing the funds. The funds are scarce, and the number of aging people is high and it grows, hence the need to control the access to services. The government-funded programs do not limit the number of claims by the health care providers. This is the reason why the federal government spending is higher than other nations within the OECD (Moreo et al., 2014). The government spending on healthcare is high.
Unlike the government-funded companies, private insurance companies offer insurance to all people that are in need of cover and that can afford the payment. The insured pay their premiums. In cases where the insured is employed, the employer contributes a certain percentage of the premiums. The government subsidizes the premiums in some cases.
The private insurance companies have to choose from a wide variety of service providers. The service providers are reimbursed depending on the service they provide. In some cases, the service providers receive lower amounts of reimbursement, forcing them to limit the service they provide to the consumers (Giunta & Cain, 2015). The private insurers focus only on the programs that do not increase their costs. They are interested in lowering their costs to increase their profits. The government programs aim at covering individuals without focusing on profits.
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The insurance companies limit the number of players in the insurance chain to cut the costs of insurance. The move limits the number of service providers and counsellors and reduces the number of individuals accessing insurance. Moreover, the insurance companies may not extend cover, especially where the first treatment did not provide adequate results (Giunta & Cain, 2015). On the other hand, the government-funded programs provide the service through care managers. The care managers provide adequate information to the government about the conditions of the consumers. Therefore, it is possible for the consumers to receive extended covers for outpatient services.
Therefore, care managers are a solution to the health care service provision. Their vast knowledge in the field helps the care providers as well as the government and insurance companies operate efficiently. Care managers provide important functions to the consumers as well. The functions of the care managers lie in helping maximize reimbursement to service providers. Consumers receive information and the right treatment by the right service providers. The service providers do not incur losses through recoup or failed reimbursement. The information that the care managers provide to the care providers helps them to use their limited resources, such as bed capacity, efficiently and record heightened incomes from insurers. The government-funded programs aim at ensuring the well-being of older populations in the USA. Therefore, they are not profit-oriented, while the insurance companies are profit-oriented and open to all citizens, unlike the government-funded programs.