Payers Module. History, Rules, and Regulations. Purpose. To provide didactic training necessary for the Case Manager to understand the various payment methodologies and their history. Program Objectives. Upon completion of this program, participants will be able to:
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History, Rules, and Regulations
To provide didactic training necessary for the Case Manager to understand the various payment methodologies and their history.
Upon completion of this program, participants will be able to:
A type of health care delivery system that attempts to manage and control access, delivery, quality, and cost of care.
Health Maintenance Organization (HMO)
Preferred Provider Organization (PPO)
Point of Service (POS)
Exclusive Provider Organization (EPO)
Physician Hospital Organization (PHO)
Management Services Organization (MSO)
Third Party Administrator (TPA)
Private or “fee for service” insurance that can be obtained by individuals on their own, or through employers or associations; allows some level of choice of healthcare provider by the insured.
Provisions prohibit Medicare from making payment if payment has been made or is expected to be made by the following primary plans:
Section 1862(b) of the Social Security Act
Medicare may make conditional payment if primary plan has not made or is not expected to make payment.
Bottom Line: Other plan pays first, Medicare pays second.
When a patient arrives in the Emergency Department, you need to assess their benefits.
Case Rate Pricing
Diagnostic Related Groups
Fee for Service (FFS)
Percent of Charges
Out of Network (Non-Par)
Various Military Plans
Remember!! They work for the payer!
……and may use different criteria
May assist with discharge planning, i.e., provides authorization for SNF, DME, HHC, transportation – they may have specific contracted providers.
Hoffman, Klees, & Curtis. (2005). Brief Summaries of Medicare & Medicaid Title XVIII and Title XIX of the Social Security Act. Centers for Medicare and Medicaid Services; Department of Health and Human Services.
Whetsell, G. W. (1999). The History and Evolution of Hospital Payment Systems: How Did We Get Here? Nursing Administration Quarterly, 23, 1-15.
Kulwsher, R.R. (2006). Medicare’s Operational History and Impact on Health Care. The Health Care Manager, 25, 53-63.References
Managed Care is defined as a type of health delivery system that:
True or False: Capitation is when the provider receives a specific amount of money based on a per member, per month basis, rather than on specific services provided.