By Duane C. Abbey
The fourth booklet within the Healthcare money System sequence, Cost-Based, Charge-Based, and Contractual check Systems compares cost-based structures, charge-based money methods, and contractually-based cost techniques with fee-schedule fee platforms and potential money platforms. providing readers with a transparent realizing of vital history fabric at the sorts of healthcare prone, it covers the fundamentals of cost-based, charge-based, and contractual cost platforms.
The booklet illustrates crucial options with a chain of straightforward case studies―making it perfect for a person attracted to studying extra in regards to the particular platforms and approaches used for cost in healthcare providers. It discusses Medicare cost-based fee structures, Medicare money methods, and comprises an appendix that outlines many of the Medicare fee platforms. Demystifying contractual language, it outlines controlled care contracts and in addition:
- Delves into the intricacies concerned with adjudication of claims
- Considers capitated check systems
- Addresses healthcare expenditures and cost-based repayment systems
- Examines charge-based and contractual money systems
- Describes the place healthcare cost structures are headed within the future
Since compliance is inherent during the means of offering companies, filling claims, and receiving fee, the publication examines the variety of compliance issues, together with statutory, contractual, and overpayment matters. utilizing quite a few examples to demonstrate the approaches used for capitated agreement preparations, the publication comprises assurance of declare adjustment, controlled care contracts, and a few of the combos of fee structures utilized by third-party directors.
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Additional info for Cost-based, charge-based, and contractual payment systems
The actual percentage above cost will be negotiated and appear in the contract. Percentages generally range in the area of 5 percent up to 15 percent. The percentage above costs should be influenced by overhead costs and any special costs for compounding certain pharmacy items. As with Dr. Brown’s clinic, the issue is to determine the cost of a particular drug and then have payment properly made at the contractual percentage above cost. Various arrangements can be made in this area, some of which are quite cumbersome.
Many private third-party payers also use a fee schedule or some modified form of a fee schedule. In addition, some DME is provided by physicians, hospitals, home health, and even SNFs. DME is different from other aspects of healthcare, even those aspects providing some sort of a product or supply item. DME can be new, used, rented, or rent to own. Thus, the ability of healthcare payers to provide payment must be quite adaptable to these different ways of dispensing DME. 15: Competing DME Suppliers Anywhere, USA, has the distinction of having nearly a dozen DME suppliers in the immediate area.
While new technology, new pharmaceuticals, and new surgical techniques all enhance the quality and efficacy of healthcare, these advances constantly challenge the payment systems to provide proper payment for medically necessary services. The most common healthcare payment systems are fee for service. This simply means that the third-party payer makes payment for services as they are provided. The greater the volume and level of complexity of services, the greater are the payments. In contrast to fee for service is the capitated payment approach.
Cost-based, charge-based, and contractual payment systems by Duane C. Abbey