Understanding Health Insurance: A Guide to Billing and Reimbursement
14th Edition
ISBN: 9781337679480
Author: GREEN
Publisher: Cengage
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In the late 20th century, many methods were used to pay physicians for services rendered. The most popular methods include all the following except payment
as a base salary.
according to a schedule of fee-for-service (FFS).
based on usual, customary, reasonable (UCR) charges.
based on resource based relative values(RBRVs).
based on patient outcomes.
Coordination of benefits (COB) includes:
Reimbursement when a patient is covered by more than 1 health plan
Reimbursement for non-covered services
Reimbursement for not medically necessary services
Reimbursement for diagnosis mismatch
The Centers for Medicare & Medicaid Services (CMS) is responsible for Accountable Care Organizations (ACOs). Describe one of the types of ACOs available to providers.
Reply to at least two (2) classmates, with a minimum of 75 words each post.
Why is it so important to accurately code diagnoses and procedures as this relates to the ACOs?
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- Even the most careful advance directive can be difficult to apply in a given set of circumstances, due to vagueness, ambiguity, lack of relevance to the patient's actual (vs. anticipated) illness, and so forth, making ethics consultations necessary, regardless of the patient's planning. Select one: True Falsearrow_forwardYou are writing your advance care directive outlining your wishes with respect to the care you will receive if you become incapacitated (ex. where would you want to receive care, what kind of care, how long, etc.). What are two things you feel strongly about that you would want to have stated in your directive? How do you think you would feel if someone said you were unable to have these wishes met because there is too much risk involved either for you or others around you?arrow_forwardThe unit manager is exploring the adoption of an electronic health records (EHRs). She is developing an evaluation tool for an objective assessment of each product. What is most important for the manager to include for assessing the functionality of each product? Select all that apply. Survey other health care organizations using EHRs to determine which one to select. The ability to integrate patient information from multiple sources for more effective clinical decision-making. List the products being considered and have the staff vote to adopt one product. Arrange for the unit staff to review a promotional video for each product and have the staff decide on what to select.arrow_forward
- A diverse patient population like blue collar workers are hard workers. Describe any facts or tips that you think are important for your classmates to know about this select population.Discuss how the clinical assessment and diagnosis may be impacted by any special characteristics or historical background of this diverse patient population. Be sure to consider how you might avoid bias during the assessment and diagnosis process.arrow_forwardDescribe a policy that is not considered to be a typical health policy but can influence health; include a brief description of what the policy is intended to accomplish and explain how the policy might influence health. The primary goal(s) of the policy that you select should fall outside of health outcomes and I encourage you to be creative. The textbook takes a very high level, narrow approach to traditional health policy, but health policies also occur outside of federal and state decision making, therefore the policy you select may exist at any level (federal, state, local, organizationalarrow_forwardYou attended an in-service education program about the outpatient prospective payment system (OPPS) where you learned that certain Medicare Part B services are paid according to ambulatory payment classifications (APCS), which group services according to similar clinical characteristics and in terms of resources required. A payment rate is established for each APC and, depending on services provided, hospitals may be paid for more than one APC for a patient encounter. As part of the in-service, you are provided with the following information and required to answer each question by applying the formula to calculate APC payments. Outpatient Prospective Payment System (OPPS) Formula (APC Weight x Conversion Factor x Wage Index) + Add-On Payments = Payment NOTE: When a patient undergoes multiple procedures and services on the same day, multiple APCS are generated and payments are added together. APC software automatically discounts multiple APC payments when appropriate (e.g., bilateral…arrow_forward
- Hello, Can you please help me with this question? (If it can be short answer, I would appreciate). Person-centered care allows patients to make informed decisions about their treatment and well-being. They have a team of primary care providers, specialists, and other health care providers who know them, listen to them, and are accountable for their care. Doctors and other healthcare professionals who provide person-centered care help patients manage their health care by providing tools and services that align with their patients’ preferences and values so they can reach their health goals" (CMS.gov, n.d., para 3). Do you believe person-centered care is possible when a client is living below the poverty line and prioritizing resources as in the 'Spent' simulation? Why or why not? You might consider access to healthcare and cost of insurance or care in your answer. Resource Name Brief description of services How do you qualify for assistance? Contact Information…arrow_forwardList and discuss the risks to a healthcare organization in failing to allocate sufficient support and resources to a newly implemented healthcare information system or EMR.arrow_forward
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