Final answer:
A contractor or fiscal intermediary determines reimbursement eligibility within healthcare finance systems like fee-for-service or HMOs, dealing with matters such as adverse selection in insurance markets and adhering to policy decisions that regulate such determinations.
Step-by-step explanation:
When a contractor or fiscal intermediary makes a ruling as to whether a service or item can be reimbursed, they are typically operating within the healthcare finance system. Under a fee-for-service health financing system, medical care providers receive reimbursement according to the cost of services they provide. This contrasts with health maintenance organizations (HMOs), where providers are reimbursed based on the number of patients they handle, rather than the services provided. Providers then must allocate resources among patients.
Issues like adverse selection can impact the dynamics of insurance markets. This occurs when insurance buyers have more information about their health risks than the insurance company. High-risk individuals may find the insurance to be a suitable deal, while low-risk individuals may forgo it due to higher costs. These intricate mechanisms of health care finance and insurance market dynamics can influence decisions on what may be reimbursable by insurance companies or government programs such as Medicare.