Healthcare reimbursement systems can be complex and difficult to understand. Each payer may use a different method to reimburse providers, or they may use a variation of a commonly used method. This course will provide a foundation for understanding the common reimbursement systems in use today.
We start with Medicare’s reimbursement systems of RBRVS, DRGs, and APCs because many other payer use modified versions of these systems. We then discuss other payer types such as HMOs, PPOs, and ACOs and how these organizations use other reimbursement methods such as capitation, per diems, and carve outs. Finally, we discuss the key data elements needed to adjudicate claims according to each scheme, and we discuss the financial incentives (and disincentives) associated with each method.
Why you should attend
This webinar is beneficial for anyone who works with medical claims and who wants a better understanding of the differences between charges and allowed amounts, how health plans and payers adjudicate claims, and how providers and payers use reimbursement methods to align incentives to manage cost and quality.
This session is also useful for provider and health plan contract managers and directors who want to build on their understanding of reimbursement mechanisms and who want to improve their contract negotiation skills.
Areas covered in the session:
- Prospective Payment Systems: DRG and APC based reimbursement;
- Typical hospital contracting structures: per diem, per stay, carve outs, case rates, minimum/maximums, etc.;
- Physician fee schedules and fee maximums, RBRVS, RVUs and capitation; and
- Major payer types (Medicare, Medicaid, HMO, PPO, ACO, etc.) and how they reimburse providers