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In July 2009, a Special Commission on the Health Care Payment System in Massachusetts distinguished between episode-based payments (i.e., bundled payments) and "global payments" that were defined as "fixed-dollar payments for the care that patients may receive in a given time period... plac[ing] providers at financial risk for both the ...
Bundled payment is the reimbursement of health care providers on the basis of expected costs for episodes of care. It has been portrayed as a middle ground between fee-for-service reimbursement and capitation (in which providers are paid a "lump sum" per patient regardless of how many services the patient receives), given that risk is shared ...
Medical billing, a payment process in the United States healthcare system, is the process of reviewing a patient's medical records and using information about their diagnoses and procedures to determine which services are billable and to whom they are billed.
Firms are often "self-insured", meaning they reimburse the insurance companies that pay the medical claims on behalf of their employees. Employers may use a stop-loss, meaning they pay the insurance company a premium to cover very expensive individual claims (e.g., the firm is self-insured up to a threshold for individual workers).
A prospective payment system (PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided. It includes a system for paying hospitals based on predetermined prices, from Medicare.
Since the late 1970s, Maryland has operated an all-payer system for hospital services. An independent commission establishes the rate structure for each hospital. That eliminated hospital cost shifting across payers, and spread more equitably the costs of uncompensated care and medical education and limited cost growth, but per capita Medicare ...
The payment model went into operation in July 2016, and barring changes to the Affordable Care Act, is slated to run until 2021. [7] [8] Over this five-year period, it is estimated that the model will be used for $6 billion spent on medical care to 155,000 patients. [9] The program is a move by the CMS to shift its focus to include specialized ...
Despite the copyrighted nature of the CPT code sets, the use of the code is mandated by almost all health insurance payment and information systems, including the Centers for Medicare and Medicaid Services (CMS), and the data for the code sets appears in the Federal Register. It is necessary for most users of the CPT code (principally providers ...