Due to the countless variables that affect revenue and cost, the hospital reimbursement process is by far the most complex of any industry. Requiring only a basic financial background and a working knowledge of accounting, Hospital Reimbursement: Concepts and Principles supplies a clear understanding of the concepts and principles that drive the revenue cycle within a hospital setting. The book explains the technical aspects of reimbursement in language that is easy to comprehend. It illustrates the complexities of the hospital revenue cycle and explains the Medicare and Medicaid financial models in detail. The text also addresses the Medicaid reimbursement methodology, the formulation of the Medicare blend rate, the computation of both DSH and IME, as well as other third-party payers.
It also: Covers the full range of services and procedures for which a hospital can receive reimbursement Explains the difference between a for-profit and not-for-profit hospital Contains chapters devoted to Statements of Operations (Income Statement) and Statements of Financial Position (Balance Sheet) Examines governmental cost reporting-including Worksheets A, A-6, A-8, A-8-2, B-1, B Part 1, C Part 1, D-3, D-5, and E Part A Supplying readers with a foundation in coding principles, the text also includes a model for calculating the financial impact of variations in patient length of stay. It discusses the DRG and APC reimbursement models and details the computation of an outlier payment. In addition, it walks the reader step-by-step through the creation of a mock Medicare cost report for a sample hospital.
Fundamentals of Accounting Introduction History and Framework Accounting Services Auditing Financial Concepts and Terminology Additional Financial Terms Financial Statements Budgeting Cost Accounting Inventory Management Sensitivity Analysis Relative Sales Value Other Ratios Conclusion References Types of Hospitals/Conceptual Framework History and Introduction Not-for-Profit Hospitals Unrelated Business Income For-Profit Hospitals Government-Owned Hospitals Board of Directors Senior Management Certificate of Need Hospital Consolidation Conclusion References Hospital Revenue Cycle Introduction Patient Access Billing Revenue Sources (Payers) Payer Mix Medical Records Case Management/Utilization Review Cash Collections Hospital Contracting Fraud/Abuse Recovery Audit Contractors Form 990 Conclusion References Hospital Services Introduction Inpatient/Outpatient Facility/Professional Fee Emergency Room Surgery Cardiology Women's Services/Birthing Unit Neonatal Intensive Care Unit Oncology Radiology Pharmacy Laboratory Observation Days Nursing Homes, Skilled Nursing Facility, Hospice Care Home Health Care Administrative Days/Swing Beds Osteopathic Medicine Conclusion Medicare Introduction and History Cost Sharing Inpatient Prospective Payment System/Diagnosis-Related Group Outpatient Prospective Payment System/APC Fee Schedule Case Mix Index Medicare Blend Rate Medicare Disproportionate Share Add-On Indirect Medical Education Add-On Capital Portion of the Blend Rate Outlier Payments Medicare Pass-Through Medicare Eligible Days Additional Issues Conclusion Medicaid Introduction Reimbursement Medicaid Add-On Payments Medicaid Teaching Supplement and Trauma Hierarchy of Indigent Patients Medicaid Cost Settlement Medicaid Disproportionate Share Calculation State Children's Hospital Insurance Program Conclusion Other Insurance Providers Introduction Managed Care (Health Maintenance Organization versus Preferred Provider Organization) Blue Cross/Blue Shield TRICARE Workers' Compensation Veterans Affairs Conclusion References Governmental Cost Reporting Introduction Worksheet A Worksheet A-6 Worksheet A-8 Worksheet A-8-1 Worksheet A-8-2 Worksheet A-7 Worksheet B-1 Worksheet B Part 1 Worksheet B Parts 2 and 3 Worksheet C Worksheet D Worksheet E Medicare Bad Debt Medicare DSH Calculation Worksheet E Part A Worksheet E Part B Subprovider (Psychiatric and Rehabilitation) Clinics Conclusion Statement of Operations (Income Statement) Introduction Gross Revenue Net Revenue Other Revenue Operating Expenses Bad Debt Responsibility Accounting Variance Analysis Payroll Conclusion Statement of Financial Position (Balance Sheet) Introduction Cash Accounts Receivable Inventories Investments Property and Equipment (Fixed Assets) Accounts Payable Long-Term Debt Other Liabilities Net Assets Statement of Changes in Net Assets Statement of Cash Flows Financial Statement Notes Conclusion Reference Coding Introduction Charge Description Master Inpatient Coding Outpatient Coding Pricing Charge Flowchart Coding Accuracy Conclusion Managing the Month-End Close Process Reference Calculating the Financial Impact of Hospital Length of Stay Introduction Hospitalist LOS Conclusion Reference The Future of Healthcare Accounting Introduction Job Security Accountable Care Organization Patient-Centered Care Bundled Payments Conclusion Epilogue Incorporating Faith in the Workplace Appendix A: UB-04 Revenue Codes Appendix B: FYE 2010 Medicare MS-DRG Listing Index