Various reimbursement methodologies Flashcards
What is the prospective payment system?
Reimbursement amount is determined before the patient receives healthcare services.
What is the fee-for-service plan?
Reimbursement amount is provided after services.
What does traditional insurance coverage use?
Fee-for-service
What is the Chargemaster/Master Charge List/Charge Description Master?
List of healthcare supplies and services along with their specific charges. (itemization for everything used for patient treatment)
Linked to computerized billing system
Matches an item to a numeric code
Generates a specific payment amount
What is traditional fee-for-service reimbursement?
When the patient or healthcare provider submits a claim to the third-party payer for healthcare services provided.
Covers medical expenses only. Mostly used by most healthcare offices today.
How are traditional fee-for-service reimbursements calculated?
Fee schedules or Usual,Customary and Reasonable (UCR) Charges
What is a fee schedule?
A list of maximum charges for a healthcare service provider under a fee-for-service basis.
What are UCR charges?
They usually reflect the costs taht are the norm for a particular geographical area.
What does the managed fee-for-service reimbursement involve?
Prospective and Retrospective review.
What is the prospective review for managed fee-for-service?
Patients case is reviewed before health care services are delivered.
What is an example of prospective review?
Pre-certification (or pre-admission certification)
What is precertification?
Obtaining approval before treatment
What is retrospective review?
Patient’s case is reviewed for appropriateness of service after discharge from hospital.
What is utilization management?
The process that evaluates the necessity and appropriateness of various healthcare services.
What is discharge planning?
Determining what the patient’s needs are after discharge. (is a type of utilization management)
What is the difference between quality assurance and utilization management?
Quality assurance assesses the quality of care provided in a particular setting.
Utilization management review the appropriateness and necessity of the healthcare services.
What is Episode-of-care (EOC) reimbursement?
One payment that is made to compensate providers for all the healthcare services provided to a patient for a specific period of time.
What is capitation (in reference to EOC reimbursement)?
Reimbursement is based on pre-established payments for a specific period of time. (managed care plan pays the healthcare provider a fixed amount on a per capita (or person) basis. If reimbursed is more than needed then physician keeps additional payment. If services provided end up being more than capitated amount, physician doesn’t get reimbursed and thus loses money.
What are global payments (in reference to EOC reimbursement)?
Made to the provider in one lump sum for all services given to the patient for a specific illness or disease.
What are the two types of global payments?
Global surgery payments
Medicare ambulatory surgery payments.
What is the ambulatory payment classification (APC) system? (formerly ambulatory patient groups APGS)
They are based on outpatient procedures performed and replace the preivous fee-for-service payment method for outpatient services.
APC’s refer to what payment system?
One of ambulatory (or outpatient) procedures provided by ambulatory surgery centers.
What are ambulatory surgery centers?
State-licensed suppliers of healthcare services that are certified by medicare. They use APC and outpatient prospective payment system (OPPS) for reimbursement classifications.
