Healthcare Valuation: The Four Pillars of Healthcare Value, Volume 1

CHAPTER 2

Reimbursement Environment

2.1 Overview

2.2 Healthcare Revenue Cycle

2.2.1 Step 1: Scheduling and Registration

2.2.2 Step 2: Patient Encounter Forms

2.2.3 Step 3: Diagnostic and Procedural Coding

2.2.4 Step 4: Charge Entry

2.2.5 Step 5: Primary Insurance Billing

2.2.6 Step 6: Secondary Insurance Billing

2.2.7 Step 7: Patient Responsibility

2.2.8 Step 8: Claims Resolution

2.2.9 Step 9: Collections

2.3 Current Reimbursement Environment

2.4 Public Payors

2.4.1 Medicare

2.4.2 Medicaid and CHIP

2.4.3 Dual Eligibles

2.4.4 TRICARE (CHAMPUS)

2.4.5 Civilian Health and Medical Program of the Department of Veteran Affairs (CHAMPVA)

2.4.6 Other Public Payors

2.5 Private Payors

2.5.1 For-Profit Commercial Insurers

2.5.2 Not-for-Profit Commercial Insurers

2.6 Methods of Reimbursement

2.6.1 Cost of Care

2.6.2 Fee-for-Service (FFS)

2.6.3 Pay-for-Performance (P4P)

2.6.4 Capitation

2.6.5 Payor Mix and the Effect on the Revenue Cycle

2.7 Emerging Reimbursement Trends and the Impact of Healthcare Reform

2.7.1 Shift from Fee-for-Service

2.7.2 ACOs

2.7.3 Patient-Centered Medical Homes

2.7.4 Vermont's Single Payor Insurance System

2.8 Conclusion

2.9 Key Sources

2.10 Acronyms

2.1 OVERVIEW

Healthcare reimbursement may be defined as the payment received by providers for the services they render to patients. Most providers will receive reimbursements for their services from commercial payors and other third parties, including, but not limited to, patients, employers, insurance companies, and ...