Differentiate between various payment methodologies
Assignment Requirements
Quoting should be less than 10% of the entire paper. Paraphrasing is necessary.
Instructions
1. Case Study: Case Study 7: Transfer Cases (I will attach the case study)
QUESTIONS:
What would you recommend that the New York State Department of Health do to address this issue with transfer cases? List at least three items along with your rational. Review the OIG website link above for additional information and background.
2. Review the “Calculation of Transfer Cases” in Exhibit 7-3 and 7-4 in your text. What do you see as the main difference in the calculations?
3. Refer to your LaTour “Health Information Management” text (found under this weeks reading tab as a hyperlinked chapter) and answer the following questions in one to two complete sentence
a. What type of payment system is in place when the amount of payment is determined before the service is delivered?
b. Which utilization control is most closely associated with managed fee-for-service reimbursement?
c. Describe the concept of capitation.
d. What were Medicare Part A payments to hospitals based on prior to implementation of the diagnosis-related group PPS?
e.What type of diagnosis is the MS-DRG prospective payment rate based on?”
4. Referring to your online Health Care Finance text, review the Exhibits 7-1 and 7-2. What is the major difference that drives why one qualifies for the outlier payment and the other does not?
5. Under the outpatient prospective payment system, Medicare decides how much a hospital or a community mental health center will be reimbursed for each service rendered. Depending on the service, the patient pays either a coinsurance amount (20%) or a fixed copayment amount, whichever is less. For each case below, determine whether the patient will pay the coinsurance or copayment amount.
a. Mr. Smith was charged $85 for a minor procedure performed in the hospital outpatient department. The fixed copayment amount for this type of procedure, adjusted for wages in the geographic area, is $15. Mr. Smith has already paid his annual Medicare Part B deductible of $100.
b. Mr. Jones and Mrs. Day live in the same area of the country. They are having the same outpatient procedure done, but at different hospitals. Mr. Jones\’s hospital charges $250 for the procedure, but Mrs. Day\’s hospital charges $150. The national median charge for this procedure is $225 (adjusted for wages in their area) with a fixed copayment of $54. Both patients have already paid their $135 yearly Medicare Part B deductible.
