In this month’s issue, the conversation on healthcare reimbursement turns to the additional prospective payment systems found across the continuum of care. Prospective payment remains a way in which the Centers for Medicare & Medicaid Services can determine the rates for care based on predetermined amounts rather than on billing. The processes are similar to the use of the diagnosis-related groups in the acute care setting, with some differences.
The goal is to provide data that will convince payors to reimburse acupuncture treatment in the emergency environment, a stumbling block that has thus far prevented larger-scale implementation. Additionally, researchers hope their work leads to fewer unnecessary opioid prescriptions.
This month will continue the discussion of healthcare reimbursement by third-party payers. We began last month with a review of the diagnosis-related groups (DRGs) and associated terminology. We will continue by reviewing how medical records are coded followed by the new MS-DRGs implemented in 2007.
It is not enough anymore to demonstrate that a surgery or imaging test is medically necessary. To receive reimbursement from health plans, patient access staff also must prove it is necessary for the procedure to happen at a hospital.
Changes in healthcare reimbursement have occurred with lightning speed over the last two decades. Providers billed for services rendered and were reimbursed — with no checks, balances, or control over costs of care. Case management, as a care delivery model, followed a similar course. But as reimbursement changed, so did case management. This month we will begin our discussion of reimbursement, including the changes to case management as it evolved with reimbursement.
EDs are using telehealth for screening visits before arrival or for follow-up re-evaluations on COVID-19-positive patients. It is important to know what can be excluded safely in a telemedicine consult, and what requires urgent and/or emergent in-person follow-up.
Risk managers should be on the alert for fraud and abuse related to reimbursement issues and financial restructuring related to the COVID-19 pandemic. With the high reimbursement rates for a COVID-19 diagnosis for hospitals and an additional large sum for the use of a ventilator, the potential for fraud and abuse in hospitals is substantial.
