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.

Contents

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 System 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 Ce...