Buch, Englisch, 181 Seiten, Format (B × H): 178 mm x 254 mm, Gewicht: 364 g
Buch, Englisch, 181 Seiten, Format (B × H): 178 mm x 254 mm, Gewicht: 364 g
ISBN: 978-1-4398-7299-4
Verlag: Productivity Press
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.
Zielgruppe
Healthcare financial professionals, collections personnel, and managed care contracting personnel; medical group practice administrators; students pursuing degrees in healthcare finance and administrations, and healthcare consultants; insurance companies and other vendors who have personnel new to the field of healthcare finance.
Autoren/Hrsg.
Fachgebiete
- Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Public Health, Gesundheitsmanagement, Gesundheitsökonomie, Gesundheitspolitik
- Wirtschaftswissenschaften Volkswirtschaftslehre Gesundheitsökonomie
- Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizin, Gesundheitswesen Krankenhausmanagement, Praxismanagement
Weitere Infos & Material
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 a
