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zz Reimburseme nt Methodologie s and Coding Compliance Sarah Sipunu, RHIA, CRC
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Healthcare Reimbursement Compensation or repayment of services already delivered Inpatient Ambulatory Post-acute care
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National Models Social Insurance (Bismarck Model) Universal healthcare coverage Employees and Employers contribute to sickness funds Redistributed by government agencies National Health Service (Beveridge Model) Government-run model Single-payer health system Private Health Insurance Premiums
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United States Healthcare Three characteristics of the U.S. healthcare sector Size of the economic sector $3.2 trillion (2015) Complexity Fragmented subsets Physicians, hospitals, rehab, chiropractors, medical equipment companies Payers Intricate payment methods and rules Payer mix Contracts between payer and facility
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Federal Payment System Centers for Medicare and Medicaid Services (CMS) Operating division within Department of Health and Human Services (HHS) Responsible for Medicare 65+, disabled, ESRD Medicaid Low-income persons and families Children’s Health Insurance Program (CHIP) Federal government is the dominant player in the healthcare sector
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Health Insurance Insurance System of reducing a person’s exposure to risk of loss by having another party (insurance company or insurer) assume the risk Risk pool Group of insureds who have similar risk of loss Premium Amount of money policyholder must pay in return for coverage
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Health Insurance Individual coverage Covers only the employee Dependent coverage Employee, spouse and children COBRA Consolidated Omnibus Budget Reconciliation Act (1985) People with loss of jobs can extend their coverage for a limited time
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Reimbursement Third-party payment/third-party payers First party is the patient (guarantor) or parent Whoever is responsible for the bill Second party is the physician, clinic, hospital, nursing home or other healthcare entity rendering care Third party is the payer Insurance company or health agency uninvolved in the direct care Examples Medicare, Private Health Insurance, Medicaid, Workers’ Comp
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Reimbursement Process Claims Request for payment for services, supplies and procedures Diagnoses for which treatment was directed Charges (fee) Set dollar amount that is the price for the item Claim Submission Claims are submitted to the insurance company (third- party) Adjudication Verification of billing requirements
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Types of Reimbursement Retrospective Based on actual resources expended to deliver services Fee schedule Predetermined list of fees that third-party payer allows Allowable charge Average or maximum amount payer will reimburse Percent of billed charges Negotiated reduced fees for their members Per diem Per day/daily rate
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Types of Reimbursement Prospective
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  • Spring '17
  •  Complexity

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