E-Book, Englisch, 181 Seiten
Abbey Cost-Based, Charge-Based, and Contractual Payment Systems
Erscheinungsjahr 2012
ISBN: 978-1-4398-7300-7
Verlag: Taylor & Francis
Format: PDF
Kopierschutz: 0 - No protection
E-Book, Englisch, 181 Seiten
ISBN: 978-1-4398-7300-7
Verlag: Taylor & Francis
Format: PDF
Kopierschutz: 0 - No protection
The fourth book in the Healthcare Payment System series, Cost-Based, Charge-Based, and Contractual Payment Systems compares cost-based systems, charge-based payment approaches, and contractually-based payment processes with fee-schedule payment systems and prospective payment systems. Supplying readers with a clear understanding of important background material on the different types of healthcare providers, it covers the basics of cost-based, charge-based, and contractual payment systems.
The book illustrates essential concepts with a series of simple case studies—making it ideal for anyone interested in learning more about the specific systems and processes used for payment in healthcare services. It discusses Medicare cost-based payment systems, Medicare payment approaches, and includes an appendix that outlines the various Medicare payment systems. Demystifying contractual language, it outlines managed care contracts and also:
- Delves into the intricacies involved with adjudication of claims
- Considers capitated payment systems
- Addresses healthcare costs and cost-based reimbursement systems
- Examines charge-based and contractual payment systems
- Describes where healthcare payment systems are headed in the future
Since compliance is inherent throughout the process of providing services, filling claims, and receiving payment, the book examines the range of compliance concerns, including statutory, contractual, and overpayment issues. Using numerous examples to illustrate the processes used for capitated contract arrangements, the book includes coverage of claim adjustment, managed care contracts, and the various combinations of payment systems used by third-party administrators.
Zielgruppe
Healthcare financial professionals, collections personnel, and managed care contracting personnel; medical group practice administrators; students pursuing degrees in healthcare finance and administrations, and healthcare consultants; insurance companies and other vendors who have personnel new to the field of healthcare finance.
Autoren/Hrsg.
Fachgebiete
- Wirtschaftswissenschaften Volkswirtschaftslehre Gesundheitsökonomie
- Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Krankenhausmanagement, Praxismanagement
- Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Public Health, Gesundheitsmanagement, Gesundheitsökonomie, Gesundheitspolitik
Weitere Infos & Material
Introduction
Preliminary Comments
Review of Healthcare Payment Systems Claims Filing and Payment Deductibles and Copayments Fee Schedule Payment Systems Prospective Payment Systems Cost-Based Payment Systems Charge-Based Payment Systems Capitation Payment Systems Contractual Payment Systems
Healthcare Provider Concepts Physicians Nonphysician Practitioners and Providers Clinics Hospitals
Hospitals and Integrated Delivery Systems Special Provider Organizations DME Suppliers Skilled Nursing Facilities Home Health Agencies Independent Diagnostic Testing Facilities Comprehensive Outpatient Rehabilitation Facilities Clinical Laboratories Ambulatory Surgical Centers
Claim Adjudication and Payment Processing
Summary and Conclusion
Healthcare Provider Costs and Cost-Based Payment Systems
Introduction
Costs and Cost Accounting
Medicare Cost Report
Cost-Based Payment: Key Features
Critical Access Hospitals
Rural Health Clinics and Federally Qualified Health Centers
Summary and Conclusion
Healthcare Provider Charges and Charge-Based Payment Systems
Introduction
Charge-Based Payment: Key Features Charge Structures for Healthcare Providers Healthcare Pricing Strategies
Chargemasters for Hospitals and Integrated Delivery Systems Charge CompressionMedicare Charging Rule Healthcare Provider Charges and Public Scrutiny
Summary and Conclusion
Contractual Payment Systems
Introduction
HIPAA Transaction Standards
Managed Care Organizations
Terminology and Contract Features Definitions Reimbursement and Payment Terms Provision of Services Payer and Payee Obligations Payment Mechanisms Credentialing Processes Medical Necessity and Coverage Issues Administrative Proceedings Access to Records and Audits
Negotiating and Analyzing MCO Contracts Precontract Data Gathering Contract and Relationship Analysis Financial Analysis and Modeling Operational Monitoring Renewal and Termination
Medicare Advantage Plans
Summary and Conclusion
Capitated Payment Systems
Introduction
Capitation: Key Features
Risk Management through Insurance
Models for Capitation
Summary and Conclusion
Claim Adjudication and Compliance
Introduction
Statutory versus Contractual Compliance
Audits and Reviews Types of Audits Audit Process Extrapolation Process Audit Reports Audit Dependence on Payment Mechanism Claim Modification Issues
A Systematic Approach to Compliance
Secondary-Payer Issues
Healthcare Provider Credentialing
Summary and Conclusion
Summary, Conclusion, and the Future
Healthcare Payment Systems: A Historical Perspective
Extreme Variability in Payment Systems
Compliance Issues
Payment Systems: The Future
Endnote
List of Acronyms
Appendix: Synopsis of the Medicare Program’s Payment Systems
Appendix: Case Study List
Index
