- 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.
- (source: Nielsen Book Data)
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.
(source: Nielsen Book Data)
