There are various prospective payment systems for outpatient, home health, physi

Question

There are various prospective payment systems for outpatient, home health, physician and nonphysician practitioners, and ambulatory surgical settings.

Instructions:

Identify two unique prospective payment systems and describe the facility types each of your selected systems are used for.

How are the unique differences in your two identified systems utilized in reimbursement? Provide an example to support your answer.

Why are all payment systems not the same? Provide an example to support your answer.

Explanation / Answer

Prospective payment system is described as payment system to determine insurance reimbursement based on pre-determine payment for actual service provided..PPS used by basically from health care providers and third-party payers..It has many variations of payments for inpatient,outpatient, skilled nursing facillities,home health agencies,long-term care and rehabilitation facilities with providers..
   Home health:
?    Medicare pays for home health agencies under prospective payment system..It is a predetermined payment system.It provides payment for patient health condition and care they needs..There are no limits for this.The home health PPS provides for each beneficiary..End of the first episodes escond episodes can begin for eligible care..The full payment in the initial percentage unless there is an applicable adjustment..
? This will be estimated according to patient condition and the care they needs..This split percentage payment and balanced cash flow for HHAs..After 60days episode can be applicable for long stay patients..Annual payment totally estamated is not more than 2.5%..Low utilization payment adjustment for four or fewer visit.This will save from reduced payment systems can be redistributed to all episodes under the PPS..
?    The PPS rate will include all services and medical supplies and medical social services..The centers for medicare and medicaid services(CMS) having problem in HH PPS rates and wage index year 2018..Medicare reimbursement 1%dropped in 2018.In 2017 the proposed rate was 180million dollar it will be less in next year.The CMS applied 3%annual payment reduction or increase in nine states but it increase to 8% in 2022..
Out patient PPS:
?    The basic rule for this OPPS and medicare Ambulatory Surgical Center(ASC) payment system needs continuing experience to arise changes in requirements..The changes for amounts and factors to determine the payment rates for medicare service paid under OPPS..This need requirement for the hospital outpatient Quality Report(OQR)program and the ASC Quaity Report program..For example in the hospital Outpatient outpatient environment imaging is not paid seperately when reports with service delivery..Packaged services do not receive seperate payment.The total outier payement at 1.0% of total OPPS payments..It continue to pay 50% of the amount hospital cost exceeds 1.75times the APC payment amount..
?    All the payemnt systems are not same the acute in patient payement provides an manage the costs of inputs needed for care..The hospitals managing th cost by eliminating unneccessary services..Same like inpatient outpatient system services similar cost wise 850 ambulatory payment classification(APC)categaries..
?    Skilled nursing facilities PPS will cover all the routine services and care..it differ for high cost ancillary services For example ventilator and tracheostomy care etc..
? Home health PPS depends the number of case provided for medicare patients..According to number of visits the cost -based payment provided a transition to prospective payemnt..
? Outpatient dialysis services will receive larger part payment that cover the dialysis treatment and samall part of drugs suppliments and lab tests..according to home dialysis,hospital dialysis payment will be differ 4 dollar per treatment..
? Physicians medicare pays for medical professionals who can give treatement and service provided directly to patient..
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