Healthcare Payment Systems

Healthcare Payment Systems: Fee Schedule Payment Systems

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Features

  • Explains the basic features of fee schedule payment systems
  • Illustrates best practices with dramatic scenarios involving a number of different services and payment approaches
  • Addresses private, third-party payers
  • Makes sense of  the highly challenging Medicare Physician Fee Schedule
  • Includes insight from one of the most respected consultants and trainers in the field

For information on other books and services by Dr. Abbey, visit www.aaciweb.com.

Summary

For healthcare providers and patients alike, the ways of private third-party payer payment systems can be mysterious and oftentimes quite frustrating. Payment for hospital, nursing, or homecare services can be subject to a variety of payment systems including cost-based and charge-based or those with payments that are determined in advance. Knowing the specific rules needed to navigate each type of payment system is essential for all healthcare administrators and accountants.

Healthcare Payment Systems: Fee Schedule Payment System, the second volume in a series by expert consultant and workshop facilitator Duane Abbey, is dedicated to fee schedule payment systems. Always accessible and entertaining in his approach, Dr. Abbey illustrates the diverse challenges involved with these systems through the discussion of reimbursement claims for several individuals in a fictitious community served by a hospital, a nursing facility, and a hospice among other healthcare providers, Including more than 60 very real scenarios that illustrate best practices for various fee payment challenges, this comprehensive volume —

  • Explores the general concept of usual, customary, and reasonable (UCR) that is often applied by private third-party payers
  • Provides web links to a number of essential resources including various government acts and manuals
  • Discusses in-depth what is arguably the most complex fee schedule system: the Medicare Physician Fee Schedule
  • Defines a comprehensive list of acronyms used in the medical payment industry

Conceptually, fee schedule payment systems are one of the simpler approaches; however, even straightforward healthcare payment systems can, and indeed do, become quite complex. No payment system exists in a vacuum. In fact, when services are provided, the reimbursement from multiple payment systems may be required. This guide shows you how all these systems work, as well as how they interface with one another in everyday practical use. Understanding the differences among systems and learning how to navigate them can make a huge difference in whether a claim is accepted or not and how much payment is allowed.

 

Table of Contents

Introduction to Fee Schedule Payment Systems
Overview of Healthcare Payment Systems
Claim Filing and Payment
Overview of Medicare Fee Schedule Payment Systems
Private Third-Party Payer and Commercial Fee Schedules
Payment System Interfaces
Healthcare Provider Use of Fee Schedules to Set Charges
Summary and Conclusion
Healthcare Provider Concepts
Introduction
Physicians
Nonphysician Practitioners and Providers
Clinics
Hospitals and Integrated Delivery Systems
Special Provider Organizations
   DME Suppliers
   Skilled Nursing Facilities
   Home Health Agencies
   Independent Diagnostic Testing Facilities
   Comprehensive Outpatient Rehabilitation Facilities
   Clinical Laboratories
   Ambulatory Surgical Centers
Summary and Conclusion
Anatomy of a Fee Schedule Payment System
Introduction
Basic Fee Schedule Payment Formula
Basic Architecture for Healthcare Fee Schedule Payment Systems
Relative Values
Classification Systems
Usual, Customary, and Reasonable
Claims and the Adjudication Process
Adjudication Features for Fee Schedules
Code Sets and Adjudication
Participating Healthcare Providers
Chapter Summary
Medicare Physician Fee Schedule
Introduction
Underlying Code Classification Structure
Payment Amounts under the MPFS
Elements in the Full MPFS
   CPT/HCPCS Codes
   Modifier
   Description
   Status Code
   Relative Value Units
   Professional Component/Technical Component Indicator
   Global Days
   Pre-Operative, Intra-Operative, Post-Operative Percentages
   Multiple Procedures
   Special Surgical Payment Indicators
   Endoscopic Base Code
   Conversion Factor
   Physician Supervision of Diagnostic Procedures
   Calculation Flag
   Diagnostic Imaging Family Indicator
   Outpatient Prospective Payment System Imaging Cap
Updating and Modifying the MPFS
Global Surgical Package
   Overview of Services Included in the GSP
   Pre-Operative Window
   Post-Operative Window
   CPT Modifiers Separating Phases within the Surgery
   Transfer of Post-Operative Care
   Anesthesia Package
Special Surgical Payment Processes
   Surgical Complications
   Co-Surgeons
   Team Surgeons
   Sequential Surgical Procedures: Separate Physicians
   Staged Surgical Procedures
   Bilateral Surgeries
Families of Codes
Nonphysician Practitioners
Special Utilization of the MPFS
   Independent Diagnostic Testing Facilities
   Comprehensive Outpatient Rehabilitation Facilities
   Critical Access Hospitals
   Ambulatory Surgical Centers
CPT and HCPCS Modifiers
National Correct Coding Initiative
    Modifiers Used to Bypass the NCCI Edits
   NCCI Coding Policies
   Medically Unlikely Edits
Gaining Extra Payment through the MPFS
Changes and Change Process for the MPFS
   Medicare Secondary Payer
Using the MPFS RVUs to Establish Charges
Summary and Conclusion
Other Medicare Fee Schedule Payment Systems
Introduction
Anesthesiology Fee Schedule
Ambulance Fee Schedule
Clinical Laboratory Fee Schedule
Durable Medical Equipment Fee Schedule
Conclusion and Summary
Private Third-Party Payer Fee Schedule Systems
Introduction
Using Medicare Fee Schedule Approaches
Usual, Customary, and Reasonable
   Basic Statistical Concepts
   Charge Data
   Statistical Analysis of Charge Data
   UCR Challenges
Establishing a UCR Schedule of Fee Payments
   Provider-Based Clinics
   Global Surgical Package
   Multiple Surgeries
   Bilateral Surgeries
   Evaluation and Management Services with Surgeries
   Assistants at Surgery
   Co-Surgeons/Multiple Surgeons
   Staged Surgical Procedures
   Surgical Families
   Anesthesia Services
   Mid-level Practitioners
   Physician Supervision
   Edits to Verify Correct Coding
   Extra Payments
   Choosing the UCR Data
   Challenges in Developing Fee Schedule Payment
Summary and Conclusion
Appendix: Case Study List
Acronym List

Author Bio(s)

Duane C. Abbey, PhD, CFP, a nationally recognized expert in payment systems, is president of Abbey and Abbey Consultants, Inc. Dr. Abbey works extensively in all areas relating to coding, billing, and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals, clinics, and physicians. Dr. Abbey. Another special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications, and/or contacted him for his services. Recently, he has begun to turn his focus towards Medicare’s new RAC audits.