An examination of the complex legal issues involved in healthcare payment and reimbursement, including fee-for-service, managed care, and Medicare/Medicaid.
Health insurance basics: The different types of health insurance plans, including private insurance, Medicare, Medicaid, and the Affordable Care Act (ACA), and how they work.
Billing and coding: The process of converting medical procedures and services into codes that are used for billing, including the International Classification of Diseases (ICD) and Current Procedural Terminology (CPT) codes.
Fraud and abuse: The types of fraud and abuse that can occur in healthcare, such as billing for services that were not provided, and the penalties that can be imposed for violations.
HIPAA: The Health Insurance Portability and Accountability Act (HIPAA) and its provisions, including the privacy and security requirements for healthcare organizations and providers.
Medicare reimbursement: How Medicare reimburses healthcare providers for services and procedures, including fee-for-service and value-based payment models, and the rules and regulations governing Medicare reimbursement.
Medicaid reimbursement: How Medicaid reimburses healthcare providers for services and procedures, including the differences between Medicaid and Medicare reimbursement, and the challenges of Medicaid reimbursement.
Managed care: The different types of managed care organizations, such as health maintenance organizations (HMOs) and preferred provider organizations (PPOs), and how they affect healthcare payment and reimbursement.
Healthcare fraud investigation and enforcement: The government agencies and regulatory bodies responsible for investigating healthcare fraud and abuse, and the role of healthcare providers and organizations in preventing and reporting fraud and abuse.
Healthcare compliance: The policies and procedures that healthcare organizations must follow to ensure that they comply with federal and state regulations, including the False Claims Act and Stark Law.
Healthcare pricing and cost containment: The factors that influence healthcare pricing, such as hospital and physician fees, and how organizations can reduce costs through clinical coordination, quality improvement, and strategic partnerships.
Fee-for-Service Payment: This is a system of payment that reimburses healthcare providers for each service that they offer to patients. Healthcare providers bill insurance plans or patients for each service and receive payment based on a pre-determined fee.
Capitation Payment: Capitation is a system of payment that reimburses healthcare providers for a fixed amount per patient per month, regardless of the number of services provided. This model typically allows for better collaboration between healthcare providers and patients in managing their healthcare needs.
Bundled Payment: This model reimburses healthcare providers for a bundle of services that are related to a specific episode of care, such as a hospitalization or surgical procedure. This system facilitates coordination between healthcare providers to optimize patient outcomes and reduce costs.
Pay-for-Performance Payment: This model incentivizes healthcare providers to meet certain quality and performance targets by offering bonuses or penalties based on their performance. The goal of this system is to improve patient outcomes and reduce costs by providing incentives for high-quality care.
Global Payment: This system of payment reimburses healthcare providers for all of the services provided to a patient over a defined period, such as a year. This system encourages providers to take a more proactive and coordinated approach to patient care to optimize outcomes and reduce costs.
Value-Based Payment: Value-based payments are designed to incentivize healthcare providers to deliver high-quality care that meets predefined healthcare goals, such as reducing hospital readmissions or improving patient satisfaction. Providers are rewarded for delivering care that achieves these goals and penalized for care that does not.
Patient-Centered Medical Home (PCMH): A PCMH is a model of care delivery that emphasizes a collaborative and coordinated approach to healthcare. This model reimburses healthcare providers for providing comprehensive and coordinated care to their patients, with the goal of improving patient outcomes and reducing costs.
Direct Payment: This model of payment involves patients paying healthcare providers directly for their services, without the involvement of insurance plans or government programs. This model is typically used for elective procedures or services that are not covered by insurance.
Accountable Care Organization (ACO): An ACO is a model of care delivery that involves groups of healthcare providers working together to coordinate care for a defined patient population. This model rewards providers for delivering high-quality care that reduces costs and improves patient outcomes.