Refer to Chapter 4
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1.
Refer to Chapter 4, focus on
Payment Methodologies
and discuss the various
payment systems. Demonstrate understanding of fee for service, cost based, and
prospective payment systems.
There are many payment methods. Payment’s methods are used only inpatient or outpatient hospitals.
There can be that payment method is defined by units’ payment for example, the time, episode, day,
service etc.
Free of service is the most traditional payment mechanism. Physician are paid for services
and test that they provide. The payer has a free schedule with a set reimbursement amount for each
service it covers.
REF
179
Cost based method is when providers or facilities submit an annual cost report that
details the
expenses of running their businesses. Under this method facility may receive payments from the payer
through the year.
A Prospective Payment System is a method of reimbursement in which Medicare payment is
made based on a predetermined, fixed amount. The payment amount for a particular service is derived
based on the classification system of that service (for example, diagnosis-related groups for inpatient
hospital services).
REF
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-
Payment/ProspMedicareFeeSvcPmtGen
2.
Explain medical necessity and how it impacts payment.
Medical necessity is a term health insurance providers use to describe whether a medical procedure is
essential for your health.
Whether your insurer deems a procedure medically necessary will determine how much of the cost, if
any, it will cover.
Instead of rejecting the claim, some payers will “downcode” it based on the diagnosis. For
example, if your doctor bills a Level 4 established office visit code (99214) when he sees you
for your sore throat, your insurance company may decide that a sore throat should never be
more complicated than a Level 3 service. In fact, the insurer may implement a process of
rejecting all Level 4 and 5 claims and require physicians to submit additional documentation
in order to be paid. This practice penalizes not only physicians who might use the higher
level codes without clinical justification, but all other physicians who actually document
according to the requirements of the higher levels. The AMA (2005) has developed policies
strongly opposing downcoding
3.
What has been the effect of payment methods on coding?
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Related Questions
Please answer question with as much detail as possible
Please Use the “NCEES FE Reference Handbook 10.0.1” which can be downloaded for Free from https://ncees.org/ as your Reference for tables and formulas
arrow_forward
Quality has been defined as customer satisfaction (or "fitness for use"). Quality can also be defined as "conformance to specifications". In theory, if you create the right specifications and then manufacture a product that meets these specifications, you should achieve customer satisfaction.
Consider the following four scenarios for a particular product:
A) Conforms to specifications and is competitive in its adequacy.
B) Conforms to specifications and is not competitive in its suitability.
C) It does not conform to specifications and is competitive in its education.
D) Does not conform to specifications and is not competitive in its education.
Which of these are not, in theory, feasible, but in practice occur and cause a lot of conceptual confusion?
Can you cite some examples?
arrow_forward
Q1: Who does what in organizations Based on this scenario only, what employer obligations to workers are likely to have been contravened?
Note: You should support your answer, where applicable, using relevant information from the scenario
arrow_forward
SUBJECT: Industrial Safety Engineering
Do not use chatgpt , draw in handwritten note and explain deeply
Draw decision tree for following machines I. Any one machine tool Pump II. Air compressor III. Internal combustion engine IV. Boiler V. Electrical motors.
arrow_forward
A manufacturing system consists of 3 machines. Parts arrive following EXPO(5) distribution. Upon arrival, the parts will be send to
the shops where they will be processed, each part will be transported individually (assume the parts move by themselves without
the need of a resource) and the move time takes UNIF(2, 3) minutes. Once the parts arrive at the shop station the parts are
distributed among the machines by selecting the machine with the shortest queue, if there are ties, then the tie breaker is the
machine index (Machine 3 is prioritized over machine 2, and 1, and machine 2 is prioritized over machine 1). There is no maximum
buffer capacity to be considered. Processing time for each machine is constant and is equal to 7 minutes. All three machines have
failure modes; the machines have up times and down time as following: Machine 1 Up Time expo(140) min, Down Time UNIF(S, 10)
min, Machine 2 up time EXPO(100) min and down time UNIF(S, 15) + 5 min while for machine 3 up time…
arrow_forward
Assignment 1: TIME VALUE OF MONEY
Objective: To further understand the concept of the time value of money.
INSTRUCTIONS:
In each problem,
a. Translate data given in problems into their respective graphical representations - i.e. draw
the correct cash flow diagram.
b. Write down all pertinent given information or data on your paper.
c. Calculate answers correctly.
3. A certain college graduate, Sallie Evans, has $24,000 in student-loan debt at the end of
her college career. The interest rate on this debt is 0.75% per month. If monthly payments
on this loan are $432.61, how many months will it take for Sallie to repay the entire loan?
arrow_forward
SUBJECT: Industrial Safety Engineering
Do not use chatgpt and draw in handwritten note
Draw decision tree for following machines I. Any one machine tool Pump II. Air compressor III. Internal combustion engine IV. Boiler V. Electrical motors.
arrow_forward
Inventory Control and Planning
Lehen Vinters imports a certain brand of beer. The demand, which may be assumed to be uniform, is 1,250,000 cases/year. The cost of ordering a shipment of beer is $500, and the cost of storing each case of beer for a year is $2. Determine how many cases of beer should be in each shipment if the ordering and storage costs are to be kept at a minimum. (Assume that each shipment of beer arrives just as the previous one has been sold.)
arrow_forward
True, False or Uncertain. Explain your answer.
Own wage elasticity JELLlincrease if product demand elasticity n? is high.
In short run, when there is an increase in wage rate, each firm will hire less labor
and so the industry labor demand is simply the horizontal summation of firm's
labor demand.
а.
b.
Labor demand is represented by the marginal revenue produce schedule (MRP)
when we have competitive product market while it will be represented by the
value of marginal product schedule (VMP) when we have a product market
monopolist.
When elasticity of substitution, SLK, increase that means the L and K are less
substitutable, and the isoquant will be L-shaped.
Minimum wage imposed by the government is always bad for the economy
because it increase unemployment and deadweight loss.
с.
d.
e.
3.
arrow_forward
2.1 You are tasked with planning of maintenance tasks at a water treatment facility. A
critical pump has failed unexpectedly, causing significant downtime. Meanwhile,
another pump of the same type has been operating without any issues. Illustrate using
a diagram the planning process that highlights the difference between a maintenance
task for an asset that has failed and a maintenance task that prevents failure from
occurring. (6)
2.2 You are the working at a power generation plant. Over the past six months, the plant
has experienced inconsistent performance from its critical assets, resulting in
occasional production losses. The maintenance team recently implemented a new
maintenance strategy to address this issue. Indicate the different methods to consider
when assessing the effectiveness of the maintenance strategy. (3)
2.3 At a manufacturing facility, operators are primarily responsible for running production
equipment, while the maintenance team handles all repairs and…
arrow_forward
As an engineer responsible for monitoring works in the area of mechanical systems, you must evaluate the following situation: a large client in the retail area has a refrigeration system where it stores some chilled or frozen products to be sold on the sales floor.Recently, the customer's maintenance department has been questioning the system's performance and requested an evaluation of the system's behavior. You went to the location and requested some information from the maintenance manager about the system, who provided the following data: - The system operates with R-134a refrigerant;- The refrigerated environment is maintained at 0°C and the external environment at 26°C;- The refrigerant flow rate in the system is 0.08 kg/s; In addition to the data provided, you carried out some tests and measured the temperature of the refrigerant fluid at some specific points in the system, such as the compressor inlet and condenser outlet, finding values of 0°C and 26°C respectively.…
arrow_forward
As an engineer responsible for monitoring works in the area of mechanical systems, you must evaluate the following situation: a large client in the retail area has a refrigeration system where it stores some chilled or frozen products to be sold on the sales floor.Recently, the customer's maintenance department has been questioning the system's performance and requested an evaluation of the system's behavior. You went to the location and requested some information from the maintenance manager about the system, who provided the following data: - The system operates with R-134a refrigerant;- The refrigerated environment is maintained at 0°C and the external environment at 26°C;- The refrigerant flow rate in the system is 0.08 kg/s; In addition to the data provided, you carried out some tests and measured the temperature of the refrigerant fluid at some specific points in the system, such as the compressor inlet and condenser outlet, finding values of 0°C and 26°C respectively.…
arrow_forward
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