By Duane C. Abbey
The fourth e-book within the Healthcare check System sequence, Cost-Based, Charge-Based, and Contractual check Systems compares cost-based platforms, charge-based cost ways, and contractually-based money tactics with fee-schedule cost platforms and potential check structures. providing readers with a transparent realizing of significant historical past fabric at the forms of healthcare services, it covers the fundamentals of cost-based, charge-based, and contractual money structures.
The ebook illustrates crucial thoughts with a chain of straightforward case studies―making it perfect for an individual drawn to studying extra concerning the particular structures and tactics used for money in healthcare companies. It discusses Medicare cost-based cost structures, Medicare check methods, and contains an appendix that outlines a number of the Medicare money structures. Demystifying contractual language, it outlines controlled care contracts and in addition:
- Delves into the intricacies concerned with adjudication of claims
- Considers capitated fee systems
- Addresses healthcare expenses and cost-based compensation systems
- Examines charge-based and contractual money systems
- Describes the place healthcare money structures are headed within the future
Since compliance is inherent through the means of delivering providers, filling claims, and receiving fee, the e-book examines the variety of compliance matters, together with statutory, contractual, and overpayment concerns. utilizing various examples to demonstrate the procedures used for capitated agreement preparations, the booklet comprises assurance of declare adjustment, controlled care contracts, and a number of the combos of cost structures utilized by third-party directors.
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Additional resources for Cost-based, charge-based, and contractual payment systems
6 is not necessarily related to the two different types of NPPs (nonphysician providers/practitioners). The decision is based on the fact that professional billing and filing claims for qualified NPPs is optional. In this case, both the CNS and NP are employed by Apex, a hospital. The difference in choosing to file claims or not will have an effect on the hospital’s cost report. For instance, if a professional claim is not filed for the practitioner’s services, then the cost of employing the practitioner will be included in the hospital’s cost report.
As with physicians, nonphysician practitioners must be credentialed to provide services and to gain billing privileges. However, a given practitioner may be employed and the employer may choose not to file claims separately for the practitioner. 6: Clinical Nurse Specialist versus Nurse Practitioner The Apex Medical Center employs a clinical nurse specialist (CNS) who is devoted to oncology services. The CNS works closely with specialty physicians in providing oncology services. Apex has decided not to file professional claims for the CNS.
Two years ago, a specialty hospital addressing only certain types of orthopedic surgeries was established about two miles down the road. The specialty hospital does not have an ED. Apex views the specialty hospital as siphoning off the more common orthopedic services, such as knee replacements and hip repairs, which are being performed at the specialty hospital. 11 illustrates the fact that hospitals can and do sometimes become competitors. Also, such a specialty hospital will probably have Medicare patients along with significant * See CMS Transmittal 87, dated May 2, 2008, to CMS Publication 100-02, Medicare Benefits Policy Manual.