E-Book, Englisch, 219 Seiten
Abbey Prospective Payment Systems
1. Auflage 2012
ISBN: 978-1-4398-7302-1
Verlag: Taylor & Francis
Format: PDF
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
E-Book, Englisch, 219 Seiten
ISBN: 978-1-4398-7302-1
Verlag: Taylor & Francis
Format: PDF
Kopierschutz: Adobe DRM (»Systemvoraussetzungen)
The third book in the Healthcare Payment Systems series, Prospective Payment Systems examines the various types of prospective payment systems (PPS) used by healthcare providers and third-party payers. Emphasizing the basic elements of PPS, it considers the many variations of payment for hospital inpatient and outpatient services, skilled nursing facilities, home health agencies, long-term hospital care, and rehabilitation facilities along with other providers.
The book describes the anatomy of PPS, including cost reports, adjudication features and processes, relative weights, and payment processes. It outlines the features and documentation requirements for Medicare Severity Diagnosis Related Groups (MS-DRGs), the Medicare Ambulatory Payment Classifications (APCs), Medicare HHPPS, Medicare Skilled Nursing Resource Utilization Groups (RUGs), and private third-party payers.
- Provides a framework for understanding and analyzing the characteristics of any PPS
- Discusses Medicare prospective payment systems and approaches
- Includes specific references to helpful resources, both online and in print
- Facilitates a clear understanding of the complexities related to PPS—covering specific topics at a high level and revisiting similar topics to reinforce understanding
Complete with a detailed listing of the acronyms most-commonly used in healthcare coding, billing, and reimbursement, the book includes a series of case studies that illustrate key concepts. It concludes with a discussion of the challenges with PPS—including compliance and overpayment issues—to provide you with the real-world understanding needed to make sense of any PPS.
Zielgruppe
Healthcare financial professionals involved with coding, billing, and reimbursement for healthcare services; collections personnel; managed care contracting personnel; medical group practice administrators; students pursuing degrees in healthcare finance and administration, and healthcare consultants. Insurance companies and other vendors who have personnel new to the field of healthcare finance.
Autoren/Hrsg.
Fachgebiete
Weitere Infos & Material
Introduction to Prospective Payment Systems
Preliminary Comments
Overview of Healthcare Payment Systems
Claims Filing and Payment
Deductibles and Copayments
Overview of Medicare Prospective Payment Systems
Private Third-Party Payer and Prospective Payment Systems
Payment System Interfaces
Healthcare Provider Use of Prospective Payment Systems to Set Charges
Summary and Conclusion
Healthcare Provider Concepts
Introduction Physicians Non-Physician Practitioners and Providers
Clinics
Hospitals
Special Hospitals with Specialized Prospective Payment Systems
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
Summary and Conclusion
Anatomy of a Prospective Payment System
Introduction
Necessary Elements PPS Coverage PPS Unit of Service PPS Classification Systems Developing Categories or Groups Determining Payment Amounts Unusual Circumstances for Additional Payments Special Incentives/Constraints
Coding for PPSs
Cost Reports
Hospital Chargemasters
Relative Weights
Conversion Factor
Chapter Summary
Medicare Severity Diagnosis Related Groups (MS-DRGs)
Introduction
Terminology
Historical Background
MS-DRG Design Features Coverage Unit of Service Classification System MS-DRG Categories MS-DRG Grouping MS-DRG Relative Weights Case-Mix Index (CMI) ICD-10 Coding: The Key for Optimizing MS-DRG Reimbursement
Conversion of M-DRGs to MS-DRGs
Payment Process Transfers Cost Outliers Special Types and Designations of Hospitals
Documentation Features
Additional Features for MS-DRGs 3-Day Preadmission Window Post-Acute Care Transfer Present on Admission (POA)
Updating Process for MS-DRGs
Variations of DRGs
Compliance Considerations
Quality Initiatives and Electronic Health Records
Summary and Conclusion
Ambulatory Payment Classifications (APCs)
Introduction
Historical Background
Challenges for Hospital Outpatient Prospective Payment
Ambulatory Patient Groups (APGs) Three-Day Window of Service Significant Procedure Consolidation E/M Service Bundling
APC Design and Implementation Parameters Medicare APC Coverage Encounter Driven APC Classification Systems: CPT and HCPCS CPT Codes and Modifiers HCPCS Codes and Modifiers National Correct Coding Initiative (NCCI) Edits APC Status Indicators (Sis) Packaging Composite APCs Discounting Global Surgical Package (GSP) Payment under APCs Special Payment Considerations APC Grouper/Pricer Deductibles and Copayments
The Provider-Based Rule Provider-Based Clinics Split Billing: 1500 plus UB-04 Establishing Fee Schedules Billing Privileges Special Situations
Ambulatory Surgical Centers
Payment System Interfaces for APCs
APCs and the Federal Register Process
Quality Reporting and Compliance for APCs
Summary and Conclusion
Other Prospective Payment Systems
Introduction
Skilled Nursing Facilities (SNFs) Coverage Classification and Grouping SNF Payment SNF Issues
Home Health Coverage Unit of Service/Unit of Payment Classification/Grouping Home Health Payment
Long-Term Care Hospitals (LTCHs) Coverage Classification and Grouping for LTCHs MS-LTC-DRG Pricer Other Features for the LTCH-PPS
Inpatient Rehabilitation Facilities
Inpatient Psychiatric Facilities (IPFs)
End-Stage Renal Dialysis (ESRD)
Private Third-Party Payer Utilization of PPSs
Summary and Conclusion
Conclusion and Endnote
Appendix A: Case Studies Chapter 1 Case Studies Chapter 2 Case Studies Chapter 3 Case Studies Chapter 4 Case Studies Chapter 5 Case Studies Chapter 6 Case Studies
Appendix B: Acronyms
