Reimbursement Flashcards
1997 – Balanced Budget Act
Medicare – adjustable fee schedule conversion factor to control costs
Co-Insurance
Portion of payment for services provided (usually 10-30%)
Common Cost Control Mechanisms
Choice of payment methodology for providers Utilization management Benefit restrictions Increased patient cost-charging Limitations on covered services Financial caps on services
Medicare part A
hospital services, SNF, home health services
No premium, daily rate depending on location
Medicare part B
outpatient services, home health services
Premium, 20% co-insurance to the patient
Medicare part C
fee for service
Medicare part D
drugs
Acute Care
Reimbursed by Inpatient Prospective Payment Rate (IPPR)
Inpatient Rehabilitation
Reimbursed by prospective payment system (PPS)
Skilled Nursing Facilities
Reimbursed by prospective bundled payment
Outpatient Therapy Services
Paid under Medicare’s physician fee schedule
Home Health Services
Prospective payment system OR physician fee schedule
Hospice Care
Paid for via daily rate schedule
Medical Home Model
Grouping patients with specific diagnoses into categories and followed by physician
Physician-directed
Coordinate access to care, monitors use of medications and speciality services
Domains of Health Policy
Cost and financing
Access and availability
Quality and outcomes
