Hospital Reimbursement : Concepts and Principles book cover
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Hospital Reimbursement
Concepts and Principles




ISBN 9781439898949
Published June 5, 2012 by Productivity Press
272 Pages

 
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Book Description

Due to the countless variables that affect revenue and cost, the hospital reimbursement process is by far the most complex of any industry. Requiring only a basic financial background and a working knowledge of accounting, Hospital Reimbursement: Concepts and Principles supplies a clear understanding of the concepts and principles that drive the revenue cycle within a hospital setting.

The book explains the technical aspects of reimbursement in language that is easy to comprehend. It illustrates the complexities of the hospital revenue cycle and explains the Medicare and Medicaid financial models in detail. The text also addresses the Medicaid reimbursement methodology, the formulation of the Medicare blend rate, the computation of both DSH and IME, as well as other third-party payers. It also:

  • Covers the full range of services and procedures for which a hospital can receive reimbursement
  • Explains the difference between a for-profit and not-for-profit hospital
  • Contains chapters devoted to Statements of Operations (Income Statement) and Statements of Financial Position (Balance Sheet)
  • Examines governmental cost reporting—including Worksheets A, A-6, A-8, A-8-2, B-1, B Part 1, C Part 1, D-3, D-5, and E Part A

Supplying readers with a foundation in coding principles, the text also includes a model for calculating the financial impact of variations in patient length of stay. It discusses the DRG and APC reimbursement models and details the computation of an outlier payment. In addition, it walks the reader step-by-step through the creation of a mock Medicare cost report for a sample hospital.

Table of Contents

Fundamentals of Accounting
Introduction
History and Framework
Accounting Services
Auditing
Financial Concepts and Terminology
Additional Financial Terms
Financial Statements
Budgeting
Cost Accounting
Inventory Management
Sensitivity Analysis
Relative Sales Value
Other Ratios
Conclusion
References

Types of Hospitals/Conceptual Framework
History and Introduction
Not-for-Profit Hospitals
Unrelated Business Income
For-Profit Hospitals
Government-Owned Hospitals
Board of Directors
Senior Management
Certificate of Need
Hospital Consolidation
Conclusion
References

Hospital Revenue Cycle
Introduction
Patient Access
Billing
Revenue Sources (Payers)
Payer Mix
Medical Records
Case Management/Utilization Review
Cash Collections
Hospital Contracting
Fraud/Abuse
Recovery Audit Contractors
Form 990
Conclusion
References

Hospital Services
Introduction
Inpatient/Outpatient
Facility/Professional Fee
Emergency Room
Surgery
Cardiology
Women’s Services/Birthing Unit
Neonatal Intensive Care Unit
Oncology
Radiology
Pharmacy
Laboratory
Observation Days
Nursing Homes, Skilled Nursing Facility, Hospice Care
Home Health Care
Administrative Days/Swing Beds
Osteopathic Medicine
Conclusion

Medicare
Introduction and History
Cost Sharing
Inpatient Prospective Payment System/Diagnosis-Related Group
Outpatient Prospective Payment System/APC Fee Schedule
Case Mix Index
Medicare Blend Rate
Medicare Disproportionate Share Add-On
Indirect Medical Education Add-On
Capital Portion of the Blend Rate
Outlier Payments
Medicare Pass-Through
Medicare Eligible Days
Additional Issues
Conclusion

Medicaid
Introduction
Reimbursement
Medicaid Add-On Payments
Medicaid Teaching Supplement and Trauma
Hierarchy of Indigent Patients
Medicaid Cost Settlement
Medicaid Disproportionate Share Calculation
State Children’s Hospital Insurance Program
Conclusion

Other Insurance Providers
Introduction
Managed Care (Health Maintenance Organization versus Preferred Provider Organization)
Blue Cross/Blue Shield
TRICARE
Workers’ Compensation
Veterans Affairs
Conclusion
References

Governmental Cost Reporting
Introduction
Worksheet A
Worksheet A-6
Worksheet A-8
Worksheet A-8-1
Worksheet A-8-2
Worksheet A-7
Worksheet B-1
Worksheet B Part 1
Worksheet B Parts 2 and 3
Worksheet C
Worksheet D
Worksheet E
Medicare Bad Debt
Medicare DSH Calculation
Worksheet E Part A
Worksheet E Part B
Subprovider (Psychiatric and Rehabilitation)
Clinics
Conclusion

Statement of Operations (Income Statement)
Introduction
Gross Revenue
Net Revenue
Other Revenue
Operating Expenses
Bad Debt
Responsibility Accounting
Variance Analysis
Payroll
Conclusion

Statement of Financial Position (Balance Sheet)
Introduction
Cash
Accounts Receivable
Inventories
Investments
Property and Equipment (Fixed Assets)
Accounts Payable
Long-Term Debt
Other Liabilities
Net Assets
Statement of Changes in Net Assets
Statement of Cash Flows
Financial Statement Notes
Conclusion
Reference

Coding
Introduction
Charge Description Master
Inpatient Coding
Outpatient Coding
Pricing
Charge Flowchart
Coding Accuracy
Conclusion

Managing the Month-End Close Process
Reference

Calculating the Financial Impact of Hospital Length of Stay
Introduction
Hospitalist LOS
Conclusion
Reference

The Future of Healthcare Accounting
Introduction
Job Security
Accountable Care Organization
Patient-Centered Care
Bundled Payments
Conclusion

Epilogue
Incorporating Faith in the Workplace
Appendix A: UB-04 Revenue Codes
Appendix B: FYE 2010 Medicare MS-DRG Listing

Index

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Author(s)

Biography

Kyle Herbert has over 18 years of healthcare accounting experience, and he is licensed as both a CPA (certified public accountant) and a CMA (certified management accountant). Kyle is a received his undergraduate degree from the University of Richmond and his master’s degree in business administration from The Citadel. In addition to these academic achievements, Kyle attained fellowships with both the Healthcare Financial Management Association and the American College of Healthcare Executives.

Kyle is a member of the American Institute of Certified Public Accountants, the Institute of Management Accountants, the South Carolina Society of Accountants, and the South Carolina Association of CPAs.

Mr. Herbert is also a Fulbright Scholar who was a visiting professor in Bangkok, Thailand.

He can be reached with questions or comments at: [email protected]

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