HCM631-0901B-01 Systems in Health Care - Phase 2 Group Project - Essay Example

The contractor, in this case, Cactus Health Care Inc., will receive prepaid capitation payment each month based on the number of individuals enrolled in the health plan. Cactus itself can provide the services to the members of the health plan and also, it can subcontract the services to another provider and reimburse them. It will be beneficial for Cactus to provide all the services rather than subcontracting them. The main reason is that Cactus already has a number of health care facilities and covering the members of the health plans will increase its base and revenues.

The primary role of Cactus Health Care Inc. will be to render all medically necessary health care services to the recipients. In case, Cactus is not enrolled as a contractor for the Health Plans, then Cactus has to submit the necessary documentation to get a reimbursement from AHCCCS. However, Cactus also has the option of being sub contracted by another contractor. In this case, Cactus can act as only a service provider to the contractor and provide health care services to the individuals enrolled to the contractor.

When operating for AHCCCS and placing a claim for reimbursement under Fee – For – Service, Cactus has to provide with the documentation proving that the recipient needed the specified medical care. Hence it is better for Cactus to act as a contractor as well as a service provider for AHCCCS. This will benefit the company in terms of the added revenue and patient flow (as a result of AHCCCS coverage). The medical services that are to be covered under AHCCCS fall in two categories, Acute Care and Long Term Care services which are covered in detail under ALTCS.

The following are the list of services to be covered under “AHCCCS Acute Care. The primary functions to be carried out have been identified and Cactus Health Inc. has to consider the issues in implementing these for the new business venture. The health plans have to be implemented in the Sun City and has to