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Methods used by the government programs to provide reimbursement to hospitals for outpatient and impatient services:
a. APC, b. DRG, c. RBRVS
Reimbursement methods commonly used by commercial payers for impatient services:
a. Fee Schedule, b. UCR Case Rate, c. Per Diem, d. Contract Rate.
Contract Rate and Capitation -
reimbursement methods commonly utilized by managed care plans for outpatient and inpatient hospital services.
a computerized system designed to capture charges for all services and items provided for the purpose of posting charges to the patient's account and billing those charges on the claim.
CMS- 1500 -
the universal claim form used to submit charges for outpatient professional services provided by a hospital-employed provider.
the INAPPROPRIATE billing sent to the patient for balances in excess of the payer's approvesd contractual amount.
codes containesd on a remittance advice of explanation of benefits sent to the hospital that desscsribes how the claim was processed.
Common reasons for claim denials:
a. Service is only payable for a specific diagnosis, b. Services does not meet standards of medical necessity with diagnosis submitted, c. The procedure is bundled in a more comprehensive procedure
Fair Debt Collection Practice Act-
a law designesd to protect consumers from unfair collection activities.
Advantages of electronic claim submission include:
a. Tracking, b. Proof of receipt, c. Processing time is reduced.
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