Examine the three types of inpatient or outpatient reimbursement systems?



CBT is found to be very productive in assisting individuals attempting to recover from addictions. CBT and the strength approach can challenge distortions and maladaptive behaviors, teaching the client new adaptive coping skills to prevent relapse.




Based on your understanding of the above statement, answer the following:




  • Identify two different types of addictions, and explain how cognitive behavior therapy (CBT) would be effective for those types.
  • Research an article that covers the effectiveness of CBT with groups. Using that information to support your work, explain the relevance and effectiveness of CBT in group therapy settings?




The development of substance dependence can be seen as part of the learning process. For instance, if you have heard from somewhere that a drink at the end of a hard day’s work lessens your stress and helps you unwind, and if commercials also advertise and support this, it means that environmental factors support your decision to use alcohol and drugs to cope with stress.




Social cognitive theory posits that human functioning results from reciprocal interactions among personal factors, such as cognitions, emotions, behaviors, and environmental conditions. It contends that learners set goals that they feel self-efficacious about attaining and believe that when attained will result in positive outcomes. Bandura’s theory identifies two types of expectations—outcome expectation and efficacy expectation. Outcome expectations are beliefs about the likely consequences of actions (Bandura, 1986).




Efficacy expectations, or self-efficacy, refer to personal beliefs about an individual’s capabilities to learn or perform actions at designated levels (Bandura, 1997).




Based on your understanding of the above, answer the following questions:




  • What is self-efficacy and what is the self-efficacy model based on?
  • Research an article that provides information on self-efficacy and addictions. Using the information provided from that and your course readings explain why self-efficacy may be important in effectively treating addictions.






Compensation and Reimbursement Plans




One way in which a MCO can control cost, quality, and access is through various structured compensation and reimbursement plans. The two most common examples are fee for service and capitation. Moreover, there are different types of reimbursement systems for inpatient and outpatient services. Answer the following questions in regard to the above information:




  • Examine the three types of inpatient or outpatient reimbursement systems?
  • Evaluate the key advantages and disadvantages of each system from the point of view of a managed care plan and the hospital?
  • What is the difference between capitation and FFS? Evaluate the type of market appropriate for each reimbursement method. Support your answer by providing an example of an MCO using either of these methods.
  • What do you understand by the term “UCR”? With what form of reimbursement is this term associated? Search current information from the Internet and evaluate the use of UCR in the managed care industry.




Reimbursement procedures are complex and detailed, especially those associated with government programs such as Medicare. Part of the regulatory requirements of Medicare is to prevent illegal billing practices such as churning, upcoding, and unbundling. You can search these topics by clicking here. You can also search on federal regulations for reimbursement procedures and fraud and compliance guidelines and education materials.




Based on your research, respond to the following questions:




  • Review the latest enforcement actions on this website. Identify a case where at least one of the following illegal actions was used—churning, upcoding, and unbundling.
  • What are some of the specific examples of actions taken against providers engaged in these practices?




After answering the above questions, read the following information:




P4P is a type of compensation method for providers based on evidence-based practices that promote better quality outcomes. Find at least two online sources of information, such as professional associations and government resources, from the South University Online library or the Internet on P4P compensation programs: one in favor of and one against this type of compensation program for providers.




Now, using the readings this week and the information gathered from the above sources:




  • Explain, in your own words, the negative consequences of P4P program.
  • Describe the market forces making this type of compensation program popular.

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