Assignment: Reimbursement Methodologies
Research prospective payment and retrospective payment systems and write a 2 page paper comparing one type of prospective payment methodology with one type of retrospective payment methodology. Include in your paper the basic characteristics of each type of methodology and "pros" and "cons" of each payment methodology.
Your paper should use APA format, including in text citations and a References page.
Make sure these are included
Correct selection of one specific prospective and one specific retrospective reimbursement methodologies
Includes the differences in the payment of claims under each reimbursement methodology
Includes the "pros" and "cons" of each reimbursement methodology
Provides appropriate citations for at least 2 research sources
How Medical Claims are paid
Reimbursement
Compensation or repayment for healthcare services
-health insurance is a primary factor in reimbursement
-Physician, Nurse practitioners, hospitals etc. are paid based on the services provided
Services are often provided before payment is made
-patient is seen inpatient or outpatient for medical care
-Appropriate treatment is given for medical condition
Depends on assignment of medical codes to describe diagnoses services and procedures provided
-Application of ICD-am CM and CPT/Hcpcs codes
Hospital Inpatient
-inpatient acute care hospital
-Inpatient Psychiatric Facility
Post-Acute Settings
-Skilled Nursing Facility
-Home Health Agency
-Inpatient Rehabilitation Facility
-long-term care Hospital
Ambulatory Setting
-outpatient Hospital Service
-Ambulatory Surgery Center
-Physician Office and Practice Groups
Reimbursement is based on the site, system, relative weighted group and perdiem
Characteristics
Retrospective payment methods
Payer learns of cost after services have been rendered
-fee scheduled-predetermined list of fees allowed for payment of health care services established by third party payers
- Discounted fee-for-service-reduced fees negotiated by third party payers for their members or insured.
Payment is present before care is delivered
-Per diem payment-limited, third party payer reimburses the provider a fixed rate for each day of hospitalization
-Case-based payment-fixed, pre-established payment for each case.
Fee for service
Providers receive payment for service rendered
-Fee is either a set amount or a set price
-Charges-fees or prices in healthcare
-Claim-list the fees or charges for each service
Episode-of care
Providers receive one lump sum for all the services they provide
-Capitated payment method
-Global payment method
Types of Reimbursement Methodologies
Payment Systems and Data Requirements
Providers are reimbursed based on the type of care provided to the patient. The patient can be an inpatient, outpatient, or a patient seen at an ambulatory surgery center.
Payment Systems
Providers are reimbursed based on the type of care provided to the patient. The patient can be an inpatient, outpatient, or a patient seen at an ambulatory surgery center.
Diagnosis Related Groups (DRG)
-Developed for the Health care Financing Administration as a patient classification scheme which provides a means of relating the type of patients a hospital treats )IE. Its case mix) to the costs incurred by the hospital. While all patients are unique, groups of patients have common demographic, diagnostic and therapeutic attributes that determine their resource needs, The DRGs from a manageable, clinically cohere net set of patient classes that relate a hospital's case mix to the resource demands and associated costs experienced by the hospital.
Medicare severity diagnosis related group)(MS-DRG)
-Based on the severity of the diagnosis; and helps shift cost and allows Medicare to pay less for cases that are not major complicated cases
Ambulatory payment Classification (APC)
-Services in each APC are similar clinically and in terms of the resources they require, A payment rate is established for each APC. Depending on the services provided, hospitals may be paid for more than one APC for an encounter.
Ambulatory surgery center group( ASC)
-The ASC payment group determines the amount that Medicare pays for facility services furnished in connection with a covered procedure.
Relative value scale (RBRVS)
-Pays physicians for the provision of health services; commonly known as the physician fee schedule.
Prospective payment Systems (PPS)
Inpatient (IPPS)
-section 1886 (d) of the social security act (the ACT) sets forth a system of payment for the operating costs of acute care hospital inpatient stays under Medicare part A (hospital Insurance) based on prospectively set rates.
Outpatient (OPPS)
-Medicare PPS used for hospital-based outpatient services and procedures. Under the OPPS, payment is predicated on the assignment of ambulatory payment classifications (APCs)