Healthcare Payment Systems An Introduction

ISBN-10: 1420092774
ISBN-13: 9781420092776
Edition: 2009
Authors: Duane C. Abbey
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Description: Healthcare payment options have become enormously complex. All providers are subject to different types of payment systems, each of which has its own variations. Making sense of the revenue cycle requires a full understanding of the payment system  More...

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Book details

Copyright year: 2009
Publisher: Productivity Press
Publication date: 5/20/2009
Binding: Paperback
Pages: 172
Size: 7.00" wide x 9.75" long x 0.50" tall
Weight: 0.792
Language: English

Healthcare payment options have become enormously complex. All providers are subject to different types of payment systems, each of which has its own variations. Making sense of the revenue cycle requires a full understanding of the payment system in use as well as the specific requirements of a third-party payer using a particular payment system. This book provides a complete introduction to healthcare payment systems. The text presents key concepts, terminology, and approaches for payment processes. Such concepts are used by providers for developing and filing claims and third-party payers and insurance companies for adjudicating and paying for healthcare services.

Acknowledgments
Healthcare Providers
Introduction
Categorizing Healthcare Providers
Hospitals-Inpatient
Hospitals-Outpatient
Ambulatory Surgical Centers
Clinics, Physicians, and Practitioners
Home Health Services
Independent Diagnostic Testing Facilities
Comprehensive Outpatient Rehabilitation Facilities
Durable Medical Equipment Suppliers
Other Types of Healthcare Providers
Medicare Provider Types
Healthcare Provider Taxonomy
Summary and Conclusion
Types of Healthcare Payment Systems
Introduction
Third-Party Payer Concept
Cost-Based Payment Systems
Charge-Based Payment Systems
Fee Schedule Payment Systems
RBRVS (Resource-Based Relative Value System)
Prospective Payment Systems
Diagnosis-Related Groups (DRGs)
Ambulatory Payment Classifications (APCs)
Home Health Agency PPS and Skilled Nursing Facilities-Resource Utilization Groups
Special and Hybrid Payment Systems
Capitated Payment Systems
Payment System Interfaces
Managed Care and Payment Systems
Medicare Advantage
Other Managed Care Payment Systems
Summary and Conclusion
Healthcare Provider Organizational Structuring
Introduction
Business Structuring
Freestanding Healthcare Providers
Solo Physician Practice
Other Freestanding Healthcare Providers
Freestanding ASCs
Freestanding Hospitals
Provider-Based Facilities
Integrated Delivery Systems
Special Organizational Structuring
Summary and Conclusion
Revenue Cycle versus Reimbursement Cycle
Introduction
The Reimbursement Cycle
Optimizing the Reimbursement Cycle
Final Product
Key Features in the Reimbursement Cycle
Special Software Interfaces
Payment System Interfaces
Summary and Conclusion
Claims Generation and Adjudication
Introduction
Three Levels of Formality for Claim Filing
Medicare Conditions for Payment
Gaining Medicare Billing Privileges
Gaining Billing Privileges with Private TPPs
Preparing and Filing Claims
Claim Adjudication
Payment and Claims Reconciliation
Summary and Conclusion
HIPAA Administrative Simplification
Introduction
HIPAA Privacy
HIPAA TSC Rule
Standard Code Sets
Current Procedural Terminology-CPT*
Healthcare Common Procedure Coding System-HCPCS
International Classification of Diseases-ICD-9-CM
Revenue Codes for the UB-04
Condition Codes for the UB-04
Place of Service Codes for the 1500
Standard Transaction Formats
National Provider Identifiers-NPIs
HIPAA Security
Summary and Conclusion
Compliance
Introduction
Coding, Billing, and Reimbursement Compliance-Overarching Issues
Medical Necessity
Claims Filing versus Claims Payment
Supporting Documentation
Statutory Compliance
Rules, Laws, and Information
Office of the Inspector General
Major Medicare Rules and Requirements
Recovery Audit Contractor Audits
Contractual Compliance
Beyond Statutory and Contractual Compliance
Establishing a Coding, Billing, and Reimbursement Compliance Program
Written Policies and Procedures
Employee Training
Monitoring and Auditing
Summary and Conclusion
Research, Problem Solving, and Knowledge-Base Development
Introduction
Systematic Process for Knowledge Management
Acquiring Information
Organizing Information
Analyzing and Assessing Information
Using the Information
Constant Change
Systematic Process for Problem Solving
Policies and Procedures
Summary and Conclusion
Case Study Listing
Chapter 1
Chapter 2
Chapter 3
Chapter 4
Chapter 5
Chapter 6
Chapter 7
Chapter 8
Acronym Listing
Index
Author

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