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Chapter 17 Reimbursement and Getting Paid

The green Module in MBC Test study guide
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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