Chapter 17 Reimbursement and Getting Paid

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The green Module in MBC Test study guide

Five types of reimbursement

1.Fee-for-service 2. Discount fee-for-Service3. Prospective Payment System (PPS) 4. Managed care organizations 5. Capitation

Contractual write-off

When the provider agrees,through a contractual agreenment, not to be paid the remaining amount of a fee after a patient has paid their deductible and coinsurance and all third party payers have paid their share

Capitation is primarily used by?

HMO (Health Management Organizations)

Three primary reimbursement systems used by Medicare:

1.Prospective Payment Systems (PPS) 2. Fee-Schedules 3. Medicare Avantage

Medicare PPS were adopted by congress under ?

The Social Security Amendments of 1983

PPS rates are set to cover costs for treating a typical inpatient in a given DRG

a. Hospital are psid a set fee for treating patients in a single DRG category. b.) There are PPS variations for different helthcare settings e.g. LTCH PPS, HH PPS, I PPS, RUGs

DRG

Diagnosis related group

LTCH PPS

Long-term Care Hospitals Prospective Payment Systems

HH PPS

Home Health Prospective Payment Systems

RUGs

Resource Utilization Groups

Five systems for determining reimbursment

1. RVS relative value scales (RVS) 2. Resource-based Relative Value Scales (RBRVS) 3. Diagnosis Related Groups 4. (DRG) Ambulatory Payment Classification (APC) 5. Resource utilization Groups (RUG)

RBRVS were adopted under which federal legislature?

(OBRA) Omnibus Budget Reconciliation Act of 1989

DRG grouper

a computer software that takes coded information and assigns the DRG category

Each DRG is assigned a ALOS

Average Length of Stay ( normally 25 Days)

RUG calculates payments for

skilled nursing facilities

LTCH PPS reimburses for

Long-Term Care Hospitals

HH PPS payment depends on

OASIS; Outcome and Assessment Information Set

Short-Stay Outlier

an adjustment to federal payment rates for LTCH stays that are cosiderably shorter than the ALOS for an LTC-DRG

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