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

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ISBN-10: 1439872996

ISBN-13: 9781439872994

Edition: 2013

Authors: Duane C. Abbey

List price: $52.99
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Description:

This fourth book in the Healthcare Payment Systemseries provides an overview of a wide range of healthcare payment systems. It compares cost-based systems, charge-based payment approaches, and contractually-based payment processes to fee-schedule payment systems and prospective payment systems. It covers claim adjustment and compliance as well as managed care contracts and various combinations of payment systems used by third-party administrators. Examples illustrate the processes used for capitated contract arrangements. The author also addresses various compliance issues, including statutory, contractual, and overpayment issues.
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Book details

List price: $52.99
Copyright year: 2013
Publisher: Productivity Press
Publication date: 8/7/2012
Binding: Paperback
Pages: 181
Size: 7.01" wide x 10.04" long x 0.43" tall
Weight: 0.792
Language: English

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