By Duane C. Abbey
The fourth booklet within the Healthcare money System sequence, Cost-Based, Charge-Based, and Contractual money Systems compares cost-based platforms, charge-based check techniques, and contractually-based check strategies with fee-schedule cost structures and potential fee platforms. providing readers with a transparent knowing of significant history fabric at the sorts of healthcare companies, it covers the fundamentals of cost-based, charge-based, and contractual money structures.
The e-book illustrates crucial suggestions with a sequence of easy case studies―making it excellent for a person drawn to studying extra in regards to the particular platforms and techniques used for money in healthcare providers. It discusses Medicare cost-based check platforms, Medicare check techniques, and contains an appendix that outlines many of the Medicare fee structures. Demystifying contractual language, it outlines controlled care contracts and in addition:
- Delves into the intricacies concerned with adjudication of claims
- Considers capitated check systems
- Addresses healthcare expenses and cost-based repayment systems
- Examines charge-based and contractual cost systems
- Describes the place healthcare check platforms are headed within the future
Since compliance is inherent during the technique of supplying providers, filling claims, and receiving money, the ebook examines the variety of compliance matters, together with statutory, contractual, and overpayment concerns. utilizing a variety of examples to demonstrate the strategies used for capitated agreement preparations, the ebook contains assurance of declare adjustment, controlled care contracts, and some 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
The challenge with using charges to drive the process is that the charge must somehow be converted into the appropriate cost to determine payment. 25 26 ◾ Cost-Based, Charge-Based, and Contractual Payment Systems Let us consider two simple case studies to illustrate the challenge with identifying costs for healthcare services. 1: Dr. Brown, a Sole Practitioner Dr. Brown is a sole practitioner in a small rural community. His clinic is about two blocks from a small rural hospital that is a CAH for Medicare purposes.
For instance, in the case of capitated payment systems, the generation of itemized statements and claims is to account for resource utilization as opposed to filing the claim for payment. In cost-based payment, claims may still be needed so that charges can be used to generate some sort of interim payment. The patient must be covered. The services rendered and items dispensed must be covered. The services are ordered and provided by qualified medical persons. The services are medically necessary.
These forms are sometimes quite lengthy, and gaining Medicare billing privileges can be challenging. Introduction ◾ 23 Note: In some cases, healthcare providers may have to file claims with third-party payers with whom they have no relationship. Technically, it is the patients who have the responsibility to make payment in these cases. However, as a practical matter, healthcare providers will generally file claims on behalf of their patients. Because there is no statutory or contractual relationship between the provider and the third-party payer, issues such as credentialing and the amount of payment that will be received can become significant issues.