1st Edition

Cost-Based, Charge-Based, and Contractual Payment Systems

181 Pages 3 B/W Illustrations

by Productivity Press

181 Pages

by Productivity Press

181 Pages

by Productivity Press

Also available as eBook on:

Taylor & Francis eBooks
(Institutional Purchase)Opens in new tab or window

Description

The fourth book in the Healthcare Payment System series, Cost-Based, Charge-Based, and Contractual Payment Systems compares cost-based systems, charge-based payment approaches, and contractually-based payment processes with fee-schedule payment systems and prospective payment systems. Supplying readers with a clear understanding of important background material on the different types of... Read more

Introduction
Preliminary Comments
Review of Healthcare Payment Systems
     Claims Filing and Payment
     Deductibles and Copayments
     Fee Schedule Payment Systems
     Prospective Payment Systems
     Cost-Based Payment Systems
     Charge-Based Payment Systems
     Capitation Payment Systems
     Contractual Payment Systems
Healthcare Provider Concepts
     Physicians
     Nonphysician Practitioners and Providers
     Clinics
     Hospitals
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
Claim Adjudication and Payment Processing
Summary and Conclusion

Healthcare Provider Costs and Cost-Based Payment Systems
Introduction
Costs and Cost Accounting
Medicare Cost Report
Cost-Based Payment: Key Features
Critical Access Hospitals
Rural Health Clinics and Federally Qualified Health Centers
Summary and Conclusion

Healthcare Provider Charges and Charge-Based Payment Systems
Introduction
Charge-Based Payment: Key Features
     Charge Structures for Healthcare Providers
     Healthcare Pricing Strategies
Chargemasters for Hospitals and Integrated Delivery Systems
     Charge CompressionMedicare Charging Rule
     Healthcare Provider Charges and Public Scrutiny
Summary and Conclusion

Contractual Payment Systems
Introduction
HIPAA Transaction Standards
Managed Care Organizations
Terminology and Contract Features
     Definitions
     Reimbursement and Payment Terms
     Provision of Services
     Payer and Payee Obligations
     Payment Mechanisms
     Credentialing Processes
     Medical Necessity and Coverage Issues
     Administrative Proceedings
     Access to Records and Audits
Negotiating and Analyzing MCO Contracts
     Precontract Data Gathering
     Contract and Relationship Analysis
     Financial Analysis and Modeling
     Operational Monitoring
     Renewal and Termination
Medicare Advantage Plans
Summary and Conclusion

Capitated Payment Systems
Introduction
Capitation: Key Features
Risk Management through Insurance
Models for Capitation
Summary and Conclusion

Claim Adjudication and Compliance
Introduction
Statutory versus Contractual Compliance
Audits and Reviews
     Types of Audits
     Audit Process
     Extrapolation Process
     Audit Reports
     Audit Dependence on Payment Mechanism
     Claim Modification Issues
A Systematic Approach to Compliance
Secondary-Payer Issues
Healthcare Provider Credentialing
Summary and Conclusion

Summary, Conclusion, and the Future
Healthcare Payment Systems: A Historical Perspective
Extreme Variability in Payment Systems
Compliance Issues
Payment Systems: The Future
Endnote

List of Acronyms

Appendix: Synopsis of the Medicare Program’s Payment Systems
Appendix: Case Study List

Index