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| Introduction | |
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| Preliminary Comments | |
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| Review of Healthcare Payment Systems | |
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| Claims Filing and Payment | |
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| Deductibles and Copayments | |
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| Fee Schedule Payment Systems | |
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| Prospective Payment Systems | |
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| Cost-Based Payment Systems | |
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| Charge-Based Payment Systems | |
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| Capitation Payment Systems | |
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| Contractual Payment Systems | |
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| Healthcare Provider Concepts | |
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| Physicians | |
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| Nonphysician Practitioners and Providers | |
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| Clinics | |
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| Hospitals | |
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| Hospitals and Integrated Delivery Systems | |
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| Special Provider Organizations | |
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| DME Suppliers | |
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| Skilled Nursing Facilities | |
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| Home Health Agencies | |
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| Independent Diagnostic Testing Facilities | |
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| Comprehensive Outpatient Rehabilitation Facilities | |
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| Clinical Laboratories | |
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| Ambulatory Surgical Centers | |
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| Claim Adjudication and Payment Processing | |
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| Summary and Conclusion | |
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| Healthcare Provider Costs and Cost-Based Payment Systems | |
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| Introduction | |
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| Costs and Cost Accounting | |
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| Medicare Cost Report | |
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| Cost-Based Payment: Key Features | |
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| Critical Access Hospitals | |
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| Rural Health Clinics and Federally Qualified Health Centers | |
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| Summary and Conclusion | |
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| Healthcare Provider Charges and Charge-Based Payment Systems | |
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| Introduction | |
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| Charge-Based Payment: Key Features | |
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| Charge Structures for Healthcare Providers | |
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| Healthcare Pricing Strategies | |
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| Chargemasters for Hospitals and Integrated Delivery Systems | |
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| Charge CompressionMedicare Charging Rule | |
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| Healthcare Provider Charges and Public Scrutiny | |
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| Summary and Conclusion | |
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| Contractual Payment Systems | |
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| Introduction | |
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| HIPAA Transaction Standards | |
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| Managed Care Organizations | |
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| Terminology and Contract Features | |
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| Definitions | |
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| Reimbursement and Payment Terms | |
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| Provision of Services | |
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| Payer and Payee Obligations | |
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| Payment Mechanisms | |
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| Credentialing Processes | |
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| Medical Necessity and Coverage Issues | |
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| Administrative Proceedings | |
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| Access to Records and Audits | |
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| Negotiating and Analyzing MCO Contracts | |
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| Precontract Data Gathering | |
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| Contract and Relationship Analysis | |
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| Financial Analysis and Modeling | |
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| Operational Monitoring | |
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| Renewal and Termination | |
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| Medicare Advantage Plans | |
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| Summary and Conclusion | |
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| Capitated Payment Systems | |
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| Introduction | |
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| Capitation: Key Features | |
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| Risk Management through Insurance | |
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| Models for Capitation | |
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| Summary and Conclusion | |
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| Claim Adjudication and Compliance | |
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| Introduction | |
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| Statutory versus Contractual Compliance | |
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| Audits and Reviews | |
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| Types of Audits | |
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| Audit Process | |
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| Extrapolation Process | |
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| Audit Reports | |
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| Audit Dependence on Payment Mechanism | |
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| Claim Modification Issues | |
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| A Systematic Approach to Compliance | |
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| Secondary-Payer Issues | |
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| Healthcare Provider Credentialing | |
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| Summary and Conclusion | |
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| Summary, Conclusion, and the Future | |
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| Healthcare Payment Systems: A Historical Perspective | |
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| Extreme Variability in Payment Systems | |
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| Compliance Issues | |
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| Payment Systems: The Future | |
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| Endnote | |
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| List of Acronyms | |
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| Appendix:Synopsis of the Medicare Program���s Payment Systems | |
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| Appendix:Case Study List | |
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| Index | |