For example 99211 is a simple short office visit cpt

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Unformatted text preview: : Maximize quantity of profitable procedures and minimize cost per procedure. o Per diagnosis: Maximize quantity of profitable cases and minimize cost per case as well as up- code. o Per day: Maximize length of stay (LOS) and minimize cost per day. o Global pricing: Maximize episodes of care and minimize cost per episode. o Value- based purchasing: Improve quality and reduce costs. Provider Incentives (capitation) o Capitation changes the playing field for providers The incentive now is to: Increase the number of covered lives, and decrease the volume of services. Provider Risks o Cost- based reimbursement: Risk is minimal o Charge- based reimbursement: Discounts will drive reimbursement below costs o Per procedure: Costs per procedure will exceed reimbursement o Per diagnosis: Costs per admission will exceed reimbursement o Per day: Costs per day will exceed reimbursement o Global pricing: Costs per episode of care will exceed reimbursement o Value- based purchasing: will neither increase quality nor reduce costs. o Capitation: Costs per member will exceed reimbursement. (Provider costs are driven by both volume and cost of services) o Different payers use different reimbursement methods, so providers face conflicting incentives and risks. Coding: the first step in the reimbursement process o Coding is performed by administrative personnel (coders) on the basis of clinicians’ notes. o There are two different types of codes used by providers- ICD codes and CPT codes o International Classification of Diseases (ICD) codes are used to specify diseases, symptoms, or injuries. The codes consist of 3, 4, or 5 digits. The greater the number, the more detailed the information ICD codes are used by hospitals to specify inpatient diagnoses o Current Procedural Terminology (CPT) codes are used to specify medical procedures (treatments) The codes are 5 digits. For example: 99211 is a simple (short) office visit CPT codes are used by physicians (and other clinicians) to specify procedures performed on patients Healthcare reform: refers to measures initially enacted by Congress in 2010 as part of the Patient Protection and Affordable Care Act (ACA). o The basic purpose of the act was to increase the number of Americans having health insurance. CHAPTER 4- Estimating Costs • • • • • Financial accounting: involves creating financial statements to report the financial status of the overall business. These statements are used primarily by outsiders Managerial accounting: involves creating information for internal use in managerial decision...
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This document was uploaded on 03/12/2014 for the course HCM 4550 at University of Minnesota Duluth.

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