Reimbursement in other health care settings

1
Reimbursement in other health care settings
2
Inpatient Hospital - General, acute care,
short-term

• Hospitals bill for
• hospital facility charges
• ancillary service charges

3

• Physician charges are not included in the
  facility charges or in the ancillary charges
• Physicians who are employees of the hospital will
  have charges billed separately reimbursement
  will come to hospital and hospital will pay MD

4

• Physicians not employed by the hospital are not
  included in hospital billing mechanisms their
  bills are generated through their office.
• Billing form - UB-92 (X12-837)

5

• Coding
• ICD-9-CM for diagnoses and procedures
• HCPCS codes on chargemaster

6

• Capturing ancillary charges
• First step begins with ancillary department
• Chargemaster a master file that contains basic
  information needed to identify, code and price an
  ancillary service

7

• Information is then submitted to business office
  for inclusion on UB-92
• Revenue codes a 3 digit code number representing
  a specific accommodation, ancillary service or
  billing calculation required for Medicare biling

8

• Must have on all hospital-based claim forms for
  outpatient and inpatient services.
• Created by CMS National and state uniform
  billing committees and CMS update the list on an
  ongoing basis

9

• Radiology - Diagnostic
• 32X
• 0 - General Classification
• 1 - Angiocardiography
• 2 - Arthrography
• etc.

10

• Payment methods
• Straight charges
• Straight discount on charges
• Per diems a single charge for a day in the
  hospital, regardless of any actual charges or
  costs incurred

11

• Case rates or package pricing flat rates for
  deliveries, CABG, etc.
• Capitation reimbursing hospital a fixed amount
  per member per month
• Prospective payment systems

12

• Prospective payment systems (PPS) the act of
  setting the payment rate in advance of a health
  care provider/practitioner rendering services.

13

• Goal reduce and control costs
• Places responsibility of managing resources on
  the provider of care
• Efficiency in providing care vs. Quality of care
  provided

14

• PPS acute care - DRGs
• Applies to Medicare and TRICARE (and sometimes
  Medicaid and other non-government third party
  payers)

15

• Exempt facilities
• Rehab hospitals and distinct rehab units
• Psych hospitals and distinct psych units
• Childrens hospitals

16

• Long-term care hospitals
• Cancer hospitals

17

• Developed by Yale University Center for Health
  Studies
• Mandated through Tax Equity and Fiscal
  Responsibility Act of 1982

18

• Key components MDCs, DRGs, relative weight,
  hospital payment rate, principal diagnosis, other
  diagnoses, procedures, age, sex and discharge
  status
• Remember HIM 218??!!

19

• The 72-Hour Rule establishes payment guidelines
  for certain preadmission services occurring 3
  calendar days preceding an inpatient admission to
  a hospital by an entity that is wholly owned or

20

• operated by the hospital.
• A hospital reimbursed under Medicares PPS must
  bill as part of the inpatient charge, a health
  care settings diagnostic services and

21

• other services (nondiagnostic services that are
  related to the inpatient admission) reimbursed
  under Medicare Part B and performed in a health
  care setting that is wholly owned or operated

22

• by the hospital within 72 hours of the patients
  admission to an acute care inpatient setting.
• See handout for scenarios

23
Ambulatory Care Settings

• Hospital-based outpatient facility, emergency
  department, observation or ambulatory surgery
  center
• Freestanding ambulatory surgery centers,
  physician offices, managed care organizations

24

• HCFA 1500
• UB-92
• Coding
• ICD-9-CM for diagnoses
• HCPCS (Levels I, II III)

25

• Observation settings - those services furnished
  by a hospital on the hospitals premises,
  including use of a bed and periodic monitoring by
  a hospitals staff, which are reasonable and

26

• necessary to evaluate an outpatients condition or
  determine the need for a possible inpatient
  admission.
• Covered only when ordered by a physician

27

• Most observation services do not exceed 1 day
• A maximum of 48 hours of observation may be
  reimbursed
• Note the hospital can ask for an exception to
  the denial of services

28

• from their FI such cases are rare.
• See examples on handout

29

• PPS for outpatients - Ambulatory Payment
  Classification (APCs)

30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
(No Transcript)