Compare and contrast the various billing and coding regulations researched in Module Two to determine which ones apply to prospective payment systems.
4-2 Journal: Payment Systems
Compare and contrast the various billing and coding regulations researched in Module Two to determine which ones apply to prospective payment systems. Reflect on how these regulations affect reimbursement in a healthcare organization. Assess the impact of regulations on reimbursement in a healthcare organization and explain what you think is working and what could be a challenge. If possible, bring in a real-world example either from your life or from something you have read about.
In 1983-1984 the Centers for Medicare and Medicaid Services (CMS) set forth a system of payment for the operating costs for healthcare organizations based on prospectively set rates. Under the Prospective Payment System (PPS), cases are also categorized into diagnosis-related groups (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat patients in that DRG.
Since providers receive a pre-established payment rate based on the assigned DRG for each case. It is to the financial advantage of the provider to deliver quality outcomes with the most effective and efficient use of resources. Providers delivering care for a cost less than the DRG payment rate benefit financially. The challenge arises for providers who deliver care to an elderly population. Or patients who suffer from chronic conditions, such as diabetes, COPD, cancer, and chronic pain. In these cases, the cost of care can be significantly greater than the DRG payment. This contributes to significant financial loss.
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