The Methods of Reimbursement Maximization in Public and Private Sectors Essay Sample

The Methods of Reimbursement Maximization in Public and Private Sectors


Nursing focuses on improving the care of individuals or community to ensure that they attain and maintain good health as well as live a quality life. It has different settings ranging from hospitals, home visits, caring for pupils at schools to doing research in pharmaceutical companies. Furthermore, it covers a wider area with the different scope of practice and the level of authority in each. Nurses help in providing the care of a client under the supervision of a skilled physician. They can also work independently in different settings in accordance with their training and collaborate with a physician, patient, and his family to help in improving the quality of life. The paper explains how the case management nurses help maximize reimbursement and the differences between governments funded and private sector programs.

How Case Managers Help to Maximize Reimbursement

Improving Outcomes

The case managers are always determined to improve the outcomes of the patient, hospitals, and health systems at large. This commitment has gone well in ensuring the maximization of the reimbursement. Due to that, the reduction in the readmissions has become an industry standard. In line with that, the nurse case managers have introduced and implemented the effective transitional care program that helps in reduction of the readmissions cases while the initiatives ensure that the patient has properly managed their medications by keeping in touch with assigned nurses after their release from the hospital (Powell 2010).

Enhancing Claims Management

A case manager is responsible for ensuring that the cost of treating a patient has been adequately catered for by the insurance company or the Medical insurance.  Additionally, the medic associate has the duty to notify the patient concerning the decision of the insurance firm on covering or not covering the medication and further treatment. In the case of the non-coverage, he intervenes by guaranteeing that the insurer has reversed the decision on behalf of the patient. Furthermore, a case manager ensures that the period the patient stays at health center is medically justified and delivered in the required setting. In case the health plan decides that the patient stay was not appropriate, the hospital can lose a lot of money paying the subsequent reimbursement.  Therefore, the hospital always tries to avoid negative reports because they can ruin the reputation of even the most reputable institution.

Admission Criteria

A nursing specialist ensures that any patient admitted to the hospital has met the existing admission criteria. This helps to avoid unnecessary people occupying the bed and leaving the critical patient without a place to be attended to (Cox 2010). Furthermore, they ensure there is an appropriate admission of the patient to the health facilities helping the hospital bottom-line as well as prevent the exposure of the patients to the diseases.

Alternative Hospitalization

They help the patients who do not meet inpatient criteria by providing alternative hospitalization and suggesting treatment. Most of the people such as elderly citizens suffer from conditions which their loved ones are unable to handle and, thus, they find it difficult to care for their family members. According to Powell (2010), the case managers help to ensure that they get assistance services such as meals, food, aids, adult day programs, and elder care services.

Patient Discharge

Case managers’ help in determining the time the patient will spend in the health facilities estimating the duration of treatment. For this reason, they gather information concerning the medical history and the living conditions of the patient from the relatives accompanying the patient. All these procedures are done when the patient is still in the emergency department and helps in tracking the family members visiting in the evening in the absence of the case manager.

Differences Between Governments funded programs and private sector

Government funded programs are those that are financed by the government using the tax payers’ money. They are designed to meet the need of all members of the public. Moreover, private sector programs, on the other hand, are funded and provided by the other than the government entities. People who are in need of these services are expected to meet the expenses by spending or using their savings.

The government funded programs such as medical insurance are subjected to the scrutiny and accountability. Since they are funded using the tax payers’ money, the government is held accountable by the public for ensuring they serve their purpose. However, public sector is not accountable to the public and therefore, provision of such services depends on the direction from the owner (Clements et al., 2012).

The former is not meant for profit making and, thus, it serves the interest of the public. For example, the government controls the health care related facilities such as medical insurance companies and hospitals with the aim of benefiting from the entire population. That distinguishes it from the latter where the motive is to generate revenues and make a profit by accumulating the money provided by the customers (Clements et al., 2012).


In conclusion, a case manager is a health care professional who coordinates the health-based services and resources that are required by individuals to meet their needs and interest. Further, case manager responds to the needs of people by ensuring that proper health services are delivered in effective and timely manner. He helps in maximizing the reimbursement by improving the outcomes, enhancing claim management, and providing alternative hospitalization among others. The government funded and the private sector programs differ by ownership type, funding operations, and the goals they pursue.

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