HSEM 380 Lecture Notes - Lecture 9: Prospective Payment System, Diagnosis Code, Payment System
22 May 2018
School
Course
Professor
ACA key components (2010)
-Accountable Care Organizations (ACOs): provide financial incentives for health care providers who
develop an integrated network to collaborate when treating patients across care settings and care
episodes
-Aim: lower health care costs while meeting quality performance standards
Patient-Centered Medical Homes (PCMHs): places of care designed to meet patients' complete needs
for mental and physical health via preventative, acute care, and disability/chronic illness management
services
Expansion of Medicaid (many states opted out)
Federal regulations for private insurance coverage (historically, no federal regulation for these)
-Essential benefits must be provided (mental health, substance abuse, behavioral health; rehab and
habilitative, chronic disease mgmt; preventative and wellness svcs)
-Pre-existing conditions
-Can't raise insurance premiums based on job/gender/pre-existing/health status/claim hx
-Coverage on parents' plan til 26 if plans cover dependents
-Can't set caps on annual and lifetime coverage
CMS
Center for Medicare and Medicaid Services
division of HHS
Facilities that participate in Medicare/Medicaid are monitored regularly for compliance w/ CMS
guidelines
-Long-term settings (i.e. SNFs) are heavily influenced by CMS guidelines bc Medicaid pays for all/most of
expense of long term care
OSHA
Standards related to safety
State accreditation
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Mandatory to obtain license for health care facility
Requirements vary by state
Enforced by state regulatory agencies
Voluntary accreditation
Most health care organizations
Status awarded for compliance w/ established standards
CMS and many states accept certain national accreditations as meeting their respectve requirements for
participation in Medicare and Medicaid programs and license to operate
JCAHO, CARF, AC-MRDD, others
Accreditation process
Initiated by organization submitting application for review or survey by accrediting agency
-Self-study/self-assessment conducted to examine organization based on accrediting agency's standards
-On-site review conducted by individual reviewer or team visiting organization
-Whole staff included
-Once accredited, undergoes periodic review, typically every 3 years
Beneficiary
Person receiving services
In SNFs, "resident" is used
Capitation
Payment system under which provider paid prospectively (i.e. on monthly basis) a set fee for each
member of specific population (i.e. health plan members) regardless if no covered health care is
delivered or if extensive care is delivered
-Payment typically determined in terms of "per member per month" (PMPM)
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-The healthier the enrollees (and fewer svcs used), the more the provider retains of the total PMPM
payment
Co-insurance
Monetary amount to be paid by a patient, usually expressed as a percentage of total charge
Clinical/critical pathway
A standardized recommendation intervention protocol for a specific diagnosis
Deductible
Amount a patient must pay to a provider before insurance benefits will pay
Usually expressed as annual dollar amount
Denial
Refusal by payer to reimburse a provider for services rendered
Reasons:
-Benefits exhausted
-Duplication of services
-Services not indicated
Diagnosis code
Describes a patient's medical reason or condition that requires health service
Diagnostic related groups (DRGs)
descriptive categories established by CMS that determine the level of payment at a per case rate
Fee for service
the payment system under which the provider is paid the same type of rate per unit of service
-Traditionally payer pays 80% and patient or provider is responsible for remaining 20%
find more resources at oneclass.com
find more resources at oneclass.com
Document Summary
Accountable care organizations (acos): provide financial incentives for health care providers who develop an integrated network to collaborate when treating patients across care settings and care episodes. Aim: lower health care costs while meeting quality performance standards. Patient-centered medical homes (pcmhs): places of care designed to meet patients" complete needs for mental and physical health via preventative, acute care, and disability/chronic illness management services. Federal regulations for private insurance coverage (historically, no federal regulation for these) Essential benefits must be provided (mental health, substance abuse, behavioral health; rehab and habilitative, chronic disease mgmt; preventative and wellness svcs) Can"t raise insurance premiums based on job/gender/pre-existing/health status/claim hx. Coverage on parents" plan til 26 if plans cover dependents. Can"t set caps on annual and lifetime coverage. Center for medicare and medicaid services division of hhs. Facilities that participate in medicare/medicaid are monitored regularly for compliance w/ cms guidelines.
