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level: Healthcare Reimbursement Methodologies

Questions and Answers List

level questions: Healthcare Reimbursement Methodologies

QuestionAnswer
ACO (Accountable Care Organization)primary care-led physician and hospital organizations that voluntarily form networks
adjudication is the process wherethe payer verifies that their billing requirements have been met, and then they determine which services are eligible for reimbursement
per capita meansper head or per person
In capitation (AKA, the capitated payment method), a 3rd party payer reimburses providers based ona fixed, per person amount for a period (usually a month)
PMPM stands forper member per month
Another term for capitation isglobal capitation
In capitation, the volume or intensity of services provided to a patienthave no effect on the payment
prospective reimbursement methodologies includecapitation, case rate, global payment, and bundled payment
prospective reimbursement is a payment method whereproviders receive a predetermined amount for all the services they provide during a timeframe
The unit of payment in prospective reimbursement isthe encounter, established period of time, or covered life
Case-rate methodology is a payment method wherethe 3rd party payer reimburses the provider one amount for the entire visit or encounter
Case-rate methodology is also known ascase-based payment
Case-rate methodology is most often used forinpatient admissions
case-rate payment rates are based onhistorical data about typical costs for patients within a group
The global payment method is a payment method wherea 3rd-party payer makes one combined payment to cover services of multiple providers who are treating a single episode-of-care.
The global payment method is typically used forphysician services and outpatient care
The contracting unit in the global payment method isthe episode of care
In a bundled payment methodology, a predetermined payment amount is provided forall services required for a single predefined episode-of-care
In bundled payment, there is usually a ________ that initiates the episode-of-care.trigger, such as a service or onset of a condition
2 criticisms of prospective payment are1) this method creates incentive to use less expensive diagnostic tests, therapeutic procedures, etc 2) creates incentive to delay or deny procedures and treatments that are costly
Retrospective payment methodologies are methods where payment is based onactual resources expended to deliver services
Examples of retrospective payment methodologies includefee schedule, percent of billed charges, and per diem
A fee schedule is based on apre-determined list of fees that a 3rd party payer will pay for certain healthcare services
Fee schedule is considered a retrospective reimbursement methodology becausewhich services and the volume of services will not be known until after care has been provided
3rd-party payers negotiate reduced fees for their members or insureds in this retrospective reimbursement methodologypercent of billed charges
The contracting unit in percent of billed charges is theclaim
The contracting unit in the fee schedule methodology is theservice
Third-party payers set per diem rates usinghistorical data
Per diem rates apply toinpatient days
Criticisms of retrospective reimbursement methodologies include1) few incentives to reduce costs 2) less incentive to order less expensive services
insurance is a system ofreducing a person's exposure to risk of loss by having another party assume the risk
A risk pool isa group of insureds who have a similar risk of loss
The premium isthe amount paid by a policyholder for a certain time period of coverage by an insurance company
3 national models of healthcare delivery are1) social insurance 2) national health insurance and 3) private health insurance
The social insurance model is also known asthe Bismarck model (originated in Germany)
The national health service model is also known asthe Beveridge model (originated in UK)
The Beveridge model is characterized asa government-run model that is a single-payer health system
Unlike in the Bismarck model, _________ determines the contribution that workers make to insurance coverage, and the contribution is not based on income.the private insurance company
3 characteristics that are key to understanding the U.S. healthcare sector are1) the size 2) the complexity and 3) the intricate payment methods and rules
DRGs went into effect this year:1983
MS-DRGs went into effect this year:2007
The inpatient psychiatric facility prospective payment system (IPF PPS) went into effect this year:2005
2 major trends of the U.S. healthcare sector are1) healthcare spending is constantly increasing and 2) efforts to reform the healthcare system
The skilled nursing facility PPS went into effect this year1998
The home health PPS went into effect this year:2000
The inpatient rehabilitation facility PPS went into effect in2002
The long-term care DRG (LTC-DRG) went into effect in2002
The payment system for hospice went into effect in1983
The payment system for ambulance services went into effect in2002
The PPS for federally qualified health centers (FQHC) went into effect in2014
The PPS for medicare end-stage renal disease facilities (ESRD) went into effect in2011
3 core problems in the US health system are1) excessive cost 2) inequitable or unsafe care 3) lack of access