Description
1. Emilia
In 1997, the Social Security Act was amended to implement Prospective Payment Systems to control the costs of hospital resources, while maintaining a level of quality care (Harrington, 2021). Since its implementation, prospective payment systems have evolved to something much greater, implementing several systems for services such as home health, physician and non-physician practitioners, and ambulatory surgical settings.The distinction between prospective payment systems for outpatients, home care, medical and non-medical, and outpatient surgical facilities is that the home care authorities provide specialized care to patients who are considered home-bound. “It is essential for healthcare leaders to differentiate the settings and meet the site specific regulations” (Harrington, 2021, p. 141). This is largely different in comparison to practitioners and surgical settings as providers are subject to their own rules, regulations, and billing scale all bound by the patient’s legal health record, entries, and coding systems for entries.
Hospital Outpatient Prospective Payment System (OPPS)
In 1999, the Balanced Budget Refinement Act added amendments to the original Prospective Payment Systems to include the development of the Hospital Outpatient Prospective Payment System, also known as OPPS (Harrington, 2021). OPPS was implemented with a diagnosis-related group (DRG)-like payment system known as Ambulatory Payment Classifications (APCs). This allows a group of codes in a payment category such as xrays, to be same rate based, creating a payment system that is more budget neutral based (Kassing & Berry, 2020). This payment system is used by Medicare to decide how much money a hospital or community mental health center will get for outpatient care provided to patients with Medicare. Services to be included are designated hospital outpatient items and services excluding clinical diagnostic laboratory services, outpatient therapy services, and screening and diagnostic mammography (Kassing & Berry, 2020). This payment system has become the foundation for other payment systems like HHPPS and payment systems used in ambulatory surgical settings. 1 Corinthians 3:11 says, “For other foundation can no man lay than that is laid, which is Jesus Christ” (King James Bible, 1769/2016). Just like with payment systems, anything we do must be done through Him. We cannot stand on any other foundation besides Jesus Christ, otherwise it will crumble.
Home Health Prospective Payment System (HH PPS)
Originally mandated in 1997, the HH PPS was a payment system implemented to assist payment and provide care for patients who are homebound unlike the OPPS which is for all other patients. These services are DMEs, skilled nursing care, various types of therapy, social work, and home health aide services (Harrington, 2021). These agencies are paid based on claims for episode-of-care time periods which is typically 60 days leaving the responsibility in the hands of the agencies as well as providers for proper documentation. This is all assessed via the OUtcome and Assessment Information Set (OASIS) to assess the level of care needed upon initial care provided as well as a continuous assessment (Harrington, 2021). This allows for proper funding to be provided as well as an increase in quality of care provided.
Physician/Non-Physician Practitioners
Physicians and non-physician practitioners are subject to their own billing scale known as the resource-based relative value scale (RBRVS) (Harrington, 2021). “RBRVS became effective on January 1,1992. To avoid major disruptions to physicians’ reimbursements, the RBRVS was gradually phased in, beginning in 1992 with full implementation by 1996 (Harrington, 2021, p. 152-153). This system was implemented to generate a more unbiased standard of assessments of encounters made by providers in comparison to the fee‐for‐service system it replaced. This allows for a comparison of resources needed to provide appropriate levels of care, taking into account labor, equipment, supplies, and more (Gao, 2018). This shifts the profit and loss system directly tied to providers and the correct entry in a patient’s medical record.
Ambulatory Surgical Centers (ASCs)
Lastly, in 2008, the ambulatory surgical centers (ASCs), centers for outpatient surgical services, established payment rates and indicators under the CPT and HCPCS codes. In order for these codes and payments to properly process an ASC must be properly certified as well as accepting of Medicare payments as payment in full (Harrington, 2021). This is all defined under CMS, separate from all other payment systems discussed previously, as all services not covered in ASCs under Medicare Part B are billed to the beneficiary (Harrington, 2021). This allows for ASCs to get paid each year as well as an expansion on the scope of services provided.
References
Gao, Y. N. (2018). Committee representation and medicare Reimbursements—An examination of the Resource‐Based relative value scale. Health Services Research, 53(6), 4353-4370. https://doi.org/10.1111/1475-6773.12857
Harrington, Michael K. Health care finance and the mechanics of insurance and reimbursement. (2nd ed.). Burlington, MA: Jones & Bartlett, 2021.
Kassing, P., & Berry, C. D. (2020). Hospital outpatient prospective payment system: A maturing prospective payment system. Journal of the American College of Radiology, 17(4), 534-541. https://doi.org/10.1016/j.jacr.2019.11.015
King James bible. (2016). Thomas Nelson. (Original work published 1769).
2. Xena
Inpatient, outpatient, home health, physician and non-physician practitioners, and ambulatory surgical settings all have separate prospective payment systems (PPS). Each environment has distinct qualities and payment systems, which I shall contrast and compare below. These many PPSs have developed to fit the unique requirements and complexity of each healthcare domain, demonstrating the significance of customizing compensation strategies to the services offered, patient populations served, and objectives of cost containment and quality improvement within each secto (Harrington, 2021)r.
The majority of services offered in hospital outpatient departments are covered by outpatient PPS. According on clinical criteria and resource usage, services are divided into Ambulatory Payment Classifications (APCs) under the Outpatient Prospective Payment System. Medicare pays a fixed amount for each service included in an APC, and payment rates are established for each APC (Erickson et al., 2020). This method encourages healthcare professionals to offer effective treatment while retaining quality. Due to the fact that compensation are fixed regardless of how much a certain patient costs, it might provide problems for institutions that serve higher-priced patients.
Medicare payments for home health services are governed by the Home Health PPS. Based on patient evaluations, it divides patients into 60-day care episodes and assigns Home Health Resource Groups (HHRGs). According on patient characteristics and anticipated resource use, payment rates are defined for each HHRG. For each episode, home health agencies are paid consistently, which promotes efficiency. Home Health PPS, as opposed to outpatient PPS, is more individualized to the needs of each patient since it takes into consideration their unique ailments and care needs (Jia et al., 2021).
The Medicare Physician Fee Schedule (MPFS) covers both physician and non-physician practitioner services. Relative Value Units (RVUs), which are based on things like doctor effort, practice costs, and malpractice charges, are assigned to each service under this method (Jia et al., 2021). Then, a conversion factor is used to translate RVUs into payment rates. Payments from the MPFS are made on a fee-for-service basis, with amounts fluctuating depending on how sophisticated the service was (Harrington, 2021). Similar to doctors, non-physician practitioners like nurse practitioners and physician assistants can bill on their own terms within their areas of expertise. The MPFS seeks to guarantee that compensation accurately represents the labor required to provide various medical services.
The ASC Payment System, which employs Ambulatory Payment Classifications (APCs) to categorize surgical operations, is used to pay Ambulatory Surgical Centers (ASCs). Medicare pays a fixed charge for each treatment, and payment rates are established for each APC (Erickson et al., 2020). To participate, ASCs must adhere to certain quality and safety requirements. ASCs are frequently more cost-effective than hospital settings for some operations since they have reduced overhead expenses (Jia et al., 2021). However, this approach might not be able to handle complicated or resource-intensive operations that are more appropriate for inpatient hospital settings.
In conclusion, various outpatient, home health, physician and non-physician practitioner, and ambulatory surgical settings have different future payment schemes. All of them strive to keep expenses in check while preserving or raising the standard of treatment. Physicians and non-physicians are paid based on fee-for-service, taking RVUs into account, whereas outpatient and home health PPSs group services and pay flat prices. Ambulatory surgical settings offer a special pricing structure that emphasizes economically sensible operations. Depending on the precise healthcare services offered and the patient group served, each system has both strengths and limitations.
One passage from the Bible that has to do with financial management is “The wise store up choice food and olive oil, but fools gulp theirs down” (Proverbs 21:20). The verse stresses the significance of caution and prudent money management. It implies that people should save and manage their resources carefully for the future rather than wasting them now. It’s important to manage one’s money with caution and foresight, just as one would store up crucial supplies like food and oil. This biblical insight promotes prudent financial management and stewardship.
References
Erickson, S. M., Outland, B., Joy, S., Rockwern, B., Serchen, J., Mire, R. D., Goldman, J. M., & Medical Practice and Quality Committee of the American College of Physicians (2020). Envisioning a Better U.S. Health Care System for All: Health Care Delivery and Payment System Reforms. Annals of internal medicine, 172(2 Suppl), S33–S49. https://doi.org/10.7326/M19-2407
Harrington, M. K. (2021). Health Care Finance: And the mechanics of Insurance and
Jia, L., Meng, Q., Scott, A., Yuan, B., & Zhang, L. (2021). Payment methods for healthcare providers working in outpatient healthcare settings. The Cochrane database of systematic reviews, 1(1), CD011865. https://doi.org/10.1002/14651858.CD011865.pub2
support assertions with at least 3 references and 1 instance of biblical integration in current APA format. Each reply must incorporate at least 2 scholarly citations and 1 instance of biblical integration in current APA format.
course textbook:
Harrington, M. K. (2021). Health Care Finance and the mechanics of Insurance and Reimbursement. Jones & Bartlett Learning.
