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Cost-Based, Charge-Based, and Contractual Payment Systems: Healthcare Payment Systems

Autor Duane C. Abbey
en Limba Engleză Paperback – 6 aug 2012
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.
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Specificații

ISBN-13: 9781439872994
ISBN-10: 1439872996
Pagini: 181
Ilustrații: 3 black & white illustrations, 2 black & white tables
Dimensiuni: 175 x 251 x 13 mm
Greutate: 0.34 kg
Ediția:New.
Editura: PRODUCTIVITY PR INC
Seria Healthcare Payment Systems


Public țintă

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.

Cuprins

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 and Conclusion Summary, Conclusion, and the Future Healthcare Payment Systems: A Historical Perspective Extreme Variability in Payment Systems Compliance Issues Payment Systems: The Future Endnote List of Acronyms Appendix: Synopsis of the Medicare Program's Payment Systems Appendix: Case Study List Index

Notă biografică

Duane C. Abbey, Ph.D., CFP, is a management consultant and president of Abbey & Abbey Consultants, Inc. Based in Ames, Iowa, Abbey & Abbey specializes in healthcare consulting and related areas. Dr. Abbey, whose work in healthcare now spans more than 25 years, earned his graduate degrees at the University of Notre Dame and Iowa State University. Today, he spends about half of his time developing and teaching workshops (for students who affectionately quip that the Federal Register is his favorite reading material) and making presentations to professional organizations. He devotes the other half to consulting work that involves performing chargemaster reviews, compliance reviews, providing litigation support, and conducting reimbursement studies. Dr. Abbey also uses his mathematical and financial background to perform financial assessments, develop complex financial models, and conduct various types of statistical work. His studies in the field of neurolinguistic programming have enhanced his ability to provide organizational communication facilitation services for healthcare organizations. He also provides litigation support services for attorneys representing healthcare providers in legal proceedings. Dr. Abbey can be contacted by e-mail at Duane@aaciweb.com. The main website for his company is : http://www.aaciweb.com.