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38 terms

Healthcare Reimbursement Systems

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prospective payment system
reimbursement methodology that establishes predetermined rates based on patient category or type of facility
prospective cost-based rates
healthcare costs from which a prospective per diem rate is determined - this method may be based on case-mix
prospective price-based rates
associated with a particular category of patient & rates are established by the payer prior to the provision of health care services
fee schedule
cost-based, fee-for-service reimbursement methodology - includes a list of maximum fees & corresponding procedures/services which payers use to compensate providers
exclusions
Medicare PPS Excluded Cancer Hospitals that applied for & were granted waivers from mandatory participation in the hospital inpatient PPS
Tax Equity and Fiscal Responsibility Act 1983 - TEFRA
legislated implementation of the inpatient prospective payment system, which uses diagnosis-related groups (DRGs) to reimburse short-term hospitals a predetermined rate for Medicare inpatient services
diagnosis-related groups
classify inpatient cases into groups that are expected to consume similar hospital resources
major diagnostic categories
DRG's that are mutually exclusive categories that are loosely based on body systems
outliers
inpatient cases that are unusually costly & the IPPS payment is increased to protect the hospital from large financial losses
UB-04
claim form submitted for inpatient care
Medicare Administrative Contractor (MAC)
third-party payer that contracts with Medicare
IPPS 3-day payment window
requires outpatient preadmission services provided by a hospital up to 3 days prior to a patient's admission to be covered by the IPPS DRG payment
Medicare Severity Diagnosis Related Groups
classification that is based on diagnoses, procedures, other demographic information & the presence of complications & comorbidities
IPPS transfer rule
any patient with a diagnosis from one of 10 CMS-determined DRGs who is discharged to a post acute provider is treated as a transfer case
post acute care settings
hospitals or distinct units excluded from the prospective payment system, skilled nursing facilities, patient's homeunder a written plan of care for the provision home health services within 3 days of discharge
present on admission indicator
assigned by the coder to the principal & secondary diagnoses and external cause of injury reported on the UB-04 form
Resident Assessment Validation and Entry/RAVEN
software developed by CMS, allows SNFs to capture & transmit the MDS (mini data sets)
resource utilization groups
prospective payment system implemented by the federal government to control costs in nursing facilities
Home Health PPS
uses home health resource groups to reimburse - requires recertification every 60 days
Outpatient PPS
uses APCs to reimburse hospital outpatient services
status indicator
assigned to each CPT & HCPCS level II code - payment indicator that dictates how each code will be paid or not paid under OPPS
Inpatient PPS
utilizes info from a patient assessment instrument to classify patients into groups based on clinical characteristics & resource needs
Long Term (Acute) PPS
uses info from long term acute care hospital patient records to classify patients into Medicare severity long term (acute) care diagnosis related groups based on clinical characteristics & resource needs
clinical laboratory fee schedule
methodology for determining fees for existing tests
national limitation amount
serves as a "cap" on the amount Medicae could pay for each test
resource based relative value system
used to reimburse physician services covered by Medicare Part B
Medicare physician fee schedule
reimburses providers according to predetermined rates assigned to services - revised by CMS annually
ambulance fee schedule
reimburses ambulance service providers a preestablished fee for each service provided
end stage renal disease composite payment rate system
for dialysis services - based on a case-mix adjusted composite rate - single payment fixed rate that doesn't vary
severity of illness
psysiologic complexity that comprises the extent & interaction of a patient's disease as presented to medical personnel
APACHE - MMPS
risk management tools that identify the risk of dying
critical pathways
interdisciplinary guidelines develpoed by hospitals to facilitate management & delivery of clinical care in a time of constrained resources
chargemaster
document that contains a computer generated list of procedures, services & supplies as well as corresponding revenue codes & charges for each
encounter form/superbill
used to record encounter data about office procedures & services
revenue code
a 4 digit UB04 code that is assigned to each procedure, service & supply to indicate the location or type of service provided to an institutional patient (radiology, laboratory)
chargemaster review process
routinely conducted by designated hospital personnel to ensure accurate reimbursement by updating CPT & HCPCS codes & linking to appropriate UB04 codes
Anti Kickback Statute
prohibits the offer, payment, receipt or solicitation of compensation for referring Medicaid/Medicare patients
Federal Claims Collection Act
established uniform procedures for gov't agencies to follow in the collection, compromise, suspension, termination or referral of litigationof debts owed to the government