Government Payor Reforms Flashcards
TEFRA
Tax Equity & Fiscal Responsibility Act of 1982
What did TEFRA establish?
Established first prospective payment system (PPS) for acute hospital care
-created DRGs
What also did TEFRA introduce?
utilization review bodies for Medicare called Peer Review Organizations (PROs)
What was the goal of DRGs?
Reduce utilization of inpatient acute care
BBA
Balanced Budget Act of 1997
Purpose of BBA
to fix hospital discharging to post acute setting
Payment for SNF
per diem
Payment for Home Health
case rate
Payment for outpatient hospitals (APCs)
case rate
Payment for Outpatient rehab & physicians (MPFS)
fee schedule
Payment for IRF
case rate
Payment for LTACH
case rate
Retrospective
payor knows how much to pay after receiving the bill from the provider
Prospective
payor knows what will be paid before receiving the bill from the provider for a given condition or length of stay (benefit for the insurer)
How is home health paid?
The first episode begins a 60 day period.
For that first episode the HH Agency (HHA) is paid 60% up front by Medicare than 40% after discharge
If the patient is discharged and restarted before that original 60 days is over, then it is a second episode and the HHA receives 50% up front and 50% at discharge.
