1st Edition

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

By Duane C. Abbey Copyright 2013
    181 Pages 3 B/W Illustrations
    by Productivity Press

    181 Pages
    by Productivity Press

    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 healthcare providers, it covers the basics of cost-based, charge-based, and contractual payment systems.

    The book illustrates essential concepts with a series of simple case studies—making it ideal for anyone interested in learning more about the specific systems and processes used for payment in healthcare services. It discusses Medicare cost-based payment systems, Medicare payment approaches, and includes an appendix that outlines the various Medicare payment systems. Demystifying contractual language, it outlines managed care contracts and also:

    • Delves into the intricacies involved with adjudication of claims
    • Considers capitated payment systems
    • Addresses healthcare costs and cost-based reimbursement systems
    • Examines charge-based and contractual payment systems
    • Describes where healthcare payment systems are headed in the future

    Since compliance is inherent throughout the process of providing services, filling claims, and receiving payment, the book examines the range of compliance concerns, including statutory, contractual, and overpayment issues. Using numerous examples to illustrate the processes used for capitated contract arrangements, the book includes coverage of claim adjustment, managed care contracts, and the various combinations of payment systems used by third-party administrators.

    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

    Biography

    Duane C. Abbey