Differences Utilized In Reimbursement

209 Words1 Page
bulb-icon

Recommended: Medicare and Medicaid difference bartleby

How are those unique differences utilized in reimbursement? Post-acute care (PAC) refers to a range of medical services that support an individual’s recovery from illness or management of a chronic illness or disability. It will provide the following hospitalization for any injury or illness, this may also require patients to continue any medical care, either provided at home or in a specialized facility. Why cannot all payment systems be the same? All payments can’t be the same due to payment adjustments that has different costs in which this will creates different reimbursements that are rendered. These services that are provided in a hospital setting can become more expensive than an outpatient services and prices can be different. Provide

Show More
Related

  • The Inpatient Prospective Payment System and OutPatient Prospective System

    969 Words  | 2 Pages

    Conversely the OPPS (outpatient prospective payment system) is controlled for different service groups such as the APCs (ambulatory payment classifications). The outpatient services in the various APCs are the same in terms of the required resources and clinical aspects. The payment rate for APC for each group is adjusted to justify the geographic differences and is applied to all of the services in this group. The health care institutions adopt a fixed amount for all the outpatient service based on the classifications of the ambulatory services. Marcinko (2006) notes that Medicare uses it to reimburse the health care providers for the items and serves which are not part of the prospective payment systems. A MPFS (Medicare physician fee schedule) determines the rate of payments for therapy and physician services based on conversion factors, relative value units, as well as, the indices costs.

    Read More

  • Chargemaster Maintenance Case Study

    1236 Words  | 3 Pages

    Furthermore, uncertainty of new reimbursement models, diminishing reimbursement, and complicated compliance regulations are playing the role of a catalyst for streamlining the Chargemaster process in majority of healthcare organizations. A good example of these challenges was prompted by the Center for Medicare and Medicaid with the release of data and chargemasters from several healthcare facilities. The release of the chargemasters sends a wave shock across the healthcare industry as it depicts a huge price discrepancies among health care providers, and due to this exposure many healthcare organizations attempt to rectify their charges. The main purpose the CMS release the chargemasters was to encourage transparency in hospital’s billing

    Read More

  • Implementation Of Orchid Leadership Rounding Tool

    1111 Words  | 3 Pages

    With the passage of the Affordable Care Act (ACA), the Centers for Medicare and Medicaid Services (CMS) has initiated reimbursement based off of patient satisfaction scores (Murphy, 2014). In fact, “CMS plans to base 30% of hospitals ' scores under the value-based purchasing initiative on patient responses to the Hospital Consumer Assessment of Healthcare Providers and Systems survey, or HCAHPS, which measures patient satisfaction” (Daly, 2011, p. 30). Consequently, a hospital’s HCAHPS score could influence 1% of a Medicare’s hospital reimbursement, which could cost between $500,000 and $850,000, depending on the organization (Murphy, 2014).

    Read More

  • Trends in Long-Term Care and Associated Implications

    1651 Words  | 4 Pages

    Long-term care (LTC) covers a wide range of clinical and social services for those who need assistance due to functional limitations. These limitations usually result from complications associated with age related chronic conditions, from disabilities related to birth defects, brain damage, or mental retardation in children; or from major illnesses or injuries suffered by adults (Shi L. & Singh D.A., 2011). LTC encompasses a variety of services including traditional clinical services, social services and housing. Unlike acute care, long-term care is much more complicated and has objectives that are much harder to measure. Acute care mainly focuses on returning patients to their previous functional level and is primarily provided by specialty providers. However, LTC mainly focuses on preventing the physical and mental deterioration of an individual and promoting social adjustments to suit the different stages of decline. In addition the providers of LTC are more diverse than those in acute care and is offered in both formal and informal settings, which include: hospitals, physicians, home care, adult day care, nursing home care, assisted living and even informal caregivers such as friends and family members. Long-term care services have been dominated by community based services, which include informal care (86%, about 10 to 11 million) and formal institutional care delivered in nursing facilities (14%, 1.6 million) (McCall, 2001). Of more than the 10 million Americans estimated to require LTC services, 58% are elderly and 42% are under the age of 65 (Shi L. & Singh D.A., 2011). The users of LTC are either frail elderly or disabled and because of the specific care needs of this population, the care varies based on an indiv...

    Read More

  • Reimbursement and Pay-for-Performance in Healthcare

    1964 Words  | 4 Pages

    Pay-for-performance (P4P) is the compensation representation that compensates healthcare contributors for accomplishing pre-authorized objectives for the delivery of quality health care assistance by economic incentives. P4P is increasingly put into practice in the healthcare structure to support quality enhancements in healthcare systems. Thus, pay-for-performance can be seen as a means of attaching financial incentives to the main objectives of clinical care. However, reimbursement is a managed care payment by a third party to a beneficiary, hospital or other health care providers for services rendered to an insured or beneficiary. This paper discusses how reimbursement can be affected by the pay-for-performance approach and how system cost reductions impact the quality and efficiency of healthcare. In addition, it also addresses how pay-for-performance affects different healthcare providers and their customers. Finally, there will also be a discussion on the effects pay-for-performance will have on the future of healthcare.

    Read More

  • Managing Healthcare Costs and Revenues

    2273 Words  | 5 Pages

    The private insurers are patients with other insurances. Under Medicare and Medicaid, services that are provided by the hospitals are paid by a prospective reimbursement. Prospective reimbursement is established before the services are provided. They have a defined dollar amount per day and per diagnosis. They also use a fee scheduled by CPT code or procedure code which is usually used for physicians. Since these types of insured patients only are billed a certain amount, most procedures are not fully reimbursed. Retrospective reimbursement is determined after the services have been delivered. This is one of the reasons organizations are struggling. Along with less reimbursement, the CPT codes or procedure codes have to be correct according to the procedure ordered. “If an organization wants to get paid, its better off taking the time to make sure all its codes are accurate, timely , and meet all payers’ requirements ”(Kapsambelis, 2004, p. 3).

    Read More

  • Medicare Reimbursement System: A Case Study

    121 Words  | 1 Pages

    As if Medicare’s declining reimbursements was not a big enough deterrent to lengthier, more satisfying higher-quality visits, Medicare’s reimbursement system actually outright punishes doctors for spending more time with patients. As the length of visit increases, Medicare reimburses physicians marginally less. For example, in the D.C. metro area, Medicare reimburses physicians $47.53 for a 10-minute follow up visit (CPT 99212), but only $154.76 for a comparable 40-minute visit (CPT 99215). Financially, doctors are better off taking care of four established patients in a 40-minute block as opposed to seeing one patient for 40 minutes. This puts additional pressure on physicians to see more patients in less time, with job satisfaction

    Read More

  • Utilization Management and Healthcare Management

    1123 Words  | 3 Pages

    The balance between quality patient care and medical necessity is a top priority and the main concern of many of the healthcare organizations today. Due to the rising cost of healthcare, there has been a change in the focus of reimbursement strategies that are affecting the delivery of patient care. This shift from a fee-for-service towards a value-based system creates a challenge that has shifted many providers’ focus more directly on their revenue. As a result, organizations are forced to take a hard look at the cost of services they are providing patients and then determining if the services and level of care are appropriate for the prescribed patient care.

    Read More

  • Health Information Management Case Study

    1610 Words  | 4 Pages

    I suspect that the codes that the physicians are submitting for payment are not accurate. Entering inaccurate codes that will yield the highest revenue for the clinic is called “upcoding”.

    Read More

  • Reimbursement Analysis

    657 Words  | 2 Pages

    A corrective helmet, my innovation for the appraisal and treatment of pediatric head trauma will be utilized on both inpatient and outpatient premise. According to a doled out textbook, Inpatient implies when a patient is expected for a hospital stay of 24 hours or an increasingly or an overnight remain. While outpatient implies regularly patients released around the same time of admission. Be that as it may, as of recent CMS has posted “two-midnight rule” i.e. patient ought to be dealt with as an outpatient until three calendar days of hospital stay. In this way, contingent upon the severity of head injury, the basis as either in/out-patient for utilization of my innovative

    Read More

  • Pharmacy Technicians

    996 Words  | 2 Pages

    trained individuals. Imagine a family member is admitted to the University of South Alabama Hospital with an acute case of pneumonia, which will require oral and intravenous medications.

    Read More

  • Importance Of Billing And Delay Reimbursement In Health Care

    1320 Words  | 3 Pages

    When reviewing the collection of data on patients it is important to first off have respect for all the sensitivity of the information you are reviewing and keeping this information private, you have access to full medical history by holding the responsibility as patient personnel. The importance of billing and collections is to review and confirm the data and documentation matches the claim and what was billed, personnel can also identify missing components or billing opportunities that were missed for additional reimbursement. Customer service is imperative because you need to interact with customers in regards to accounts, information verification, or balances owed. Exceptional customer service ensures that you value the customer and are willing to work with them and help,

    Read More

  • Case Management

    919 Words  | 2 Pages

    In 1983, the Medicare prospective payment program was implemented, which allowed hospitals to be reimbursed a set payment based on the patient’s diagnosis, or Diagnosis Related Groups (DRG), regardless of what treatment was provided or how long the patient was hospitalized (Jacob & Cherry, 2007).... ... middle of paper ... ... Case Management Related to Other Nursing Care Delivery Models.

    Read More

  • The Revenue Cycle in Healthcare

    866 Words  | 2 Pages

    There are several factors that contribute to the complexity of the revenue cycle. Frequent changes in contracts with payers, legislative mandates, and managed care are just a few examples of reasons why revenue cycle in the healthcare industry is so complex. Furthermore, the problems that arise in the steps of the revenue cycle further complicate the whole process. For example, going through the steps of the revenue cycle efficiently is extremely difficult when it is managed by poorly trained personnel. Furthermore, if a healthcare provider does not have the proper information system to track patient records and billing, receiving reimbursement can become difficult. In addition, one of the main factors that delay payments is denial from the insurance companies. The reason for Denial includes incorrect coding, the certain sequence of care and medical necessity or even delay in submitting claims. Lastly, inefficient patient correspondence can not only hinder the process of revenue cycle but also result in many patient complaints (Wolper, 2004).

    Read More

  • Medical Classification In Healthcare

    800 Words  | 2 Pages

    There are over 500 groups within the system. Each group has a particular payment weight behind it, which allows the hospital to determine how much to charge for services. The exact weight used by each hospital depends on its geographic location, the percentage of low-income patients within the group, if it is a teaching hospital, and whether a particular case involved higher expenses than normal.

    Read More

More about Differences Utilized In Reimbursement

Open Document