Prospective Payment Systems

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

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

Biography

Duane C. Abbey