WGU C428 Financial Resource Management in Healthcare PA
|Latest Update with Complete Solution
Gabriel Flores
ID Number: XXXXXXXX
Course: Financial Resource Management in Healthcare - C428
Date: 11/13/2024
A1. Propose Three fiscally sustainable strategies for Seamus Company from the
perspective of a CFO, moving away from a fee-for-service model to a MCO model.
1. The first option I would suggest would be the Health Management Organization, or also
known as an HMO plan. This plan is structured as a network of Healthcare options made
up of Doctors, Hospitals and various other healthcare providers. This structure provides
continuity of care from approved healthcare providers and establishments that have
already agreed to accept payment for services rendered at a previously agreed upon level.
(Humana, 2024) HMO plans operate under a referral based system to eliminate
unnecessary specialist visits and other various 7healthcare services. The patient is
assigned a Primary care physician that treats the patient in a general sense, and when a
need arises that would require the consult of a specialist, the Primary Care Physician
sends a referral on behalf of the patient for the services or specialist needed. But, referrals
can only be sent to specialists within the network of healthcare providers participating in
the HMO, this provides continuity of care and eliminates the need of unnecessary services.
HMO plans will not cover patient visits to healthcare services without the proper referrals in
place. And even then, HMO plans do require pre-authorizations for any requested services
even if recommended by a doctor. The HMO plan reviews the case and determines if the
services requested are appropriate or unnecessary. This is a beneficial structure for the
CFO to implement for Seamus company as it can automatically weed out unnecessary
services that patient’s may be opting for that they should not be receiving. This provides a
solid structure for patients to receive necessary care at affordable prices that would also
benefit the company in terms of simple cost saving.
2. The next plan I would recommend would be a Preferred Provider Organization otherwise
, known as a PPO plan, which presents a lot more flexibility in terms of options as opposed
to the HMO Plan mentioned above. A PPO plan allows patients the option to see providers
that are out of network, but at a higher cost on the part of the patient. For patients it would
typically be beneficial to them when they’re recommended to go to a specific healthcare
provider but they happen to not be in network with the patient’s plan. With a HMO plan,
unfortunately coverage for an out of network provider is not an option, but a PPO plan
allows for out of network benefits just at a higher cost to the patient. If the patient wants to
opt to spend more money out of their own pocket to see the out of network provider, they
have the freedom to be able to do that. Another aspect of the flexibility of a PPO plan is the
requirement of a referral from a PCP for a visit to a specialist and a PCP is not even needed
with a PPO Plan. With a PPO plan fiscal sustainability presents itself as the patient agrees
beforehand to be willing to pay more for the flexibility of being able to receive the services
they want without having to jump through many hoops to get them. This would prove to
benefit the company financially because the patient would cover extra costs associated
with the services they’ve requested.
3. The last plan I would implement would be the Point of Service plan otherwise referred to
as a POS plan. This sort of plan is a hybrid of sorts between the PPO and HMO plans.
Where a PPO doesn’t require a PCP because it doesn’t require referrals to be able to see
specialists, a POS plan does require referrals from a PCP but the referrals can go to out of
network providers. But just as the PPO plan, any out of network providers will require a high
out of pocket cost for the patient to be able to utilize. This sort of plan can be beneficial for
patients that would still like to be able to see out of network providers but also have a
network of in network providers that can be seen at a lower out of pocket cost. Another
relevant component of POS plans in terms of fiscal sustainability is the tax benefits
associated with the plan's structure. The premiums for these plans paid for by the
employer are also exempt from payroll taxes such as Medicare and Social Security. This is
beneficial not only to the Seamus company but also It's employees that choose this sort of
plan.
A1a. Recommend a plan to carry out each of the three from part A1 by including the
following:
(1) Cost-saving measures
(2) Tax deductible considerations
(3) Other tax advantages
(4) Fiscal management improvements
|Latest Update with Complete Solution
Gabriel Flores
ID Number: XXXXXXXX
Course: Financial Resource Management in Healthcare - C428
Date: 11/13/2024
A1. Propose Three fiscally sustainable strategies for Seamus Company from the
perspective of a CFO, moving away from a fee-for-service model to a MCO model.
1. The first option I would suggest would be the Health Management Organization, or also
known as an HMO plan. This plan is structured as a network of Healthcare options made
up of Doctors, Hospitals and various other healthcare providers. This structure provides
continuity of care from approved healthcare providers and establishments that have
already agreed to accept payment for services rendered at a previously agreed upon level.
(Humana, 2024) HMO plans operate under a referral based system to eliminate
unnecessary specialist visits and other various 7healthcare services. The patient is
assigned a Primary care physician that treats the patient in a general sense, and when a
need arises that would require the consult of a specialist, the Primary Care Physician
sends a referral on behalf of the patient for the services or specialist needed. But, referrals
can only be sent to specialists within the network of healthcare providers participating in
the HMO, this provides continuity of care and eliminates the need of unnecessary services.
HMO plans will not cover patient visits to healthcare services without the proper referrals in
place. And even then, HMO plans do require pre-authorizations for any requested services
even if recommended by a doctor. The HMO plan reviews the case and determines if the
services requested are appropriate or unnecessary. This is a beneficial structure for the
CFO to implement for Seamus company as it can automatically weed out unnecessary
services that patient’s may be opting for that they should not be receiving. This provides a
solid structure for patients to receive necessary care at affordable prices that would also
benefit the company in terms of simple cost saving.
2. The next plan I would recommend would be a Preferred Provider Organization otherwise
, known as a PPO plan, which presents a lot more flexibility in terms of options as opposed
to the HMO Plan mentioned above. A PPO plan allows patients the option to see providers
that are out of network, but at a higher cost on the part of the patient. For patients it would
typically be beneficial to them when they’re recommended to go to a specific healthcare
provider but they happen to not be in network with the patient’s plan. With a HMO plan,
unfortunately coverage for an out of network provider is not an option, but a PPO plan
allows for out of network benefits just at a higher cost to the patient. If the patient wants to
opt to spend more money out of their own pocket to see the out of network provider, they
have the freedom to be able to do that. Another aspect of the flexibility of a PPO plan is the
requirement of a referral from a PCP for a visit to a specialist and a PCP is not even needed
with a PPO Plan. With a PPO plan fiscal sustainability presents itself as the patient agrees
beforehand to be willing to pay more for the flexibility of being able to receive the services
they want without having to jump through many hoops to get them. This would prove to
benefit the company financially because the patient would cover extra costs associated
with the services they’ve requested.
3. The last plan I would implement would be the Point of Service plan otherwise referred to
as a POS plan. This sort of plan is a hybrid of sorts between the PPO and HMO plans.
Where a PPO doesn’t require a PCP because it doesn’t require referrals to be able to see
specialists, a POS plan does require referrals from a PCP but the referrals can go to out of
network providers. But just as the PPO plan, any out of network providers will require a high
out of pocket cost for the patient to be able to utilize. This sort of plan can be beneficial for
patients that would still like to be able to see out of network providers but also have a
network of in network providers that can be seen at a lower out of pocket cost. Another
relevant component of POS plans in terms of fiscal sustainability is the tax benefits
associated with the plan's structure. The premiums for these plans paid for by the
employer are also exempt from payroll taxes such as Medicare and Social Security. This is
beneficial not only to the Seamus company but also It's employees that choose this sort of
plan.
A1a. Recommend a plan to carry out each of the three from part A1 by including the
following:
(1) Cost-saving measures
(2) Tax deductible considerations
(3) Other tax advantages
(4) Fiscal management improvements
