The third book in the Healthcare Payment Systems series, Prospective Payment Systems examines the various types of prospective payment systems (PPS) used by healthcare providers and third-party payers. Emphasizing the basic elements of PPS, it considers the many variations of payment for hospital inpatient and outpatient services, skilled nursing facilities, home health agencies, long-term hospital care, and rehabilitation facilities along with other providers.

The book describes the anatomy of PPS, including cost reports, adjudication features and processes, relative weights, and payment processes. It outlines the features and documentation requirements for Medicare Severity Diagnosis Related Groups (MS-DRGs), the Medicare Ambulatory Payment Classifications (APCs), Medicare HHPPS, Medicare Skilled Nursing Resource Utilization Groups (RUGs), and private third-party payers.

Provides a framework for understanding and analyzing the characteristics of any PPS Discusses Medicare prospective payment systems and approaches Includes specific references to helpful resources, both online and in print Facilitates a clear understanding of the complexities related to PPS—covering specific topics at a high level and revisiting similar topics to reinforce understanding

Complete with a detailed listing of the acronyms most-commonly used in healthcare coding, billing, and reimbursement, the book includes a series of case studies that illustrate key concepts. It concludes with a discussion of the challenges with PPS—including compliance and overpayment issues—to provide you with the real-world understanding needed to make sense of any PPS.

Contents

Introduction to Prospective Payment Systems

Preliminary Comments

Overview of Healthcare Payment Systems

Claims Filing and Payment

Deductibles and Copayments

Overview of Medicare Prospective Payment Systems

Private Third-Party Payer and Prospective Payment Systems

Payment Systemces

Healthcare Provider Use of Prospective Payment Systems to Set Charges

Summary and Conclusion

Healthcare Provider Concepts

Introduction

Physicians

Non-Physician Practitioners and Providers

Clinics

Hospitals

Special Hospitals with Specialized Prospective Payment Systems

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

Summary and Conclusion

Anatomy of a Prospective Payment System

Introduction

Necessary Elements

PPS Coverage

PPS Unit of Service

PPS Classification Systems

Developing Categories or Groups

Determining Payment Amounts

U...