project 2

Running Head: CMS PAYMENT SYSTEM 1

CMS PAYMENT SYSTEM 5

CMS Payment System

Name:

Institutional Affiliation:

CMS Payment System

Question 1

A PPS, that is, a prospective Payment System is a method used in reimbursement whereby the payment of Medicare gets made basing upon an amount that is fixed and predetermined. The payment quantity for a specific service gets derived regarding the classification system of the service in question. For instance, groups which are diagnosis-related for hospital services offering inpatient services. The CMS system of payment uses diverse PPS for compensation to skilled nursing centers, inpatient rehab centers, hospital outpatient and agencies offering home health.

ICD, also known as International Classification of Diseases is the foundation that identifies the health statistics and trends universally as well as the worldwide customs used for the commentary regarding diseases and conditions pertaining health. This classification is the standard problem-solving method for all clinical purposes besides examination. Also, one could define it as, "standard diagnostic tool for epidemiology, health management and clinical purposes" (Bradley & Taylor, 2013)

If your healthcare provider agrees to take your insurance cover for offering diverse services, it means that she or he has accepted the reimbursement schedule of your payer. Therefore, the provider does not expect you to give any more funds for the services which you will receive except if he or she lets you know beforehand (Glaser, 2013). The act of billing a patient for any extra amount without being informed is illegal and is known as “balance billing.”

Question 2

i. Value-Based Reimbursement

Here, providers get compensations under free-for-service prototypes with an effective and quality constituent.

ii. Bundled Payments

Under these payments, the providers of healthcare get reimbursed for distinct incidents of care.

iii. Fee-for-Service

This approach is comprised of particular rates that get negotiated for every service or procure performed. When it comes to overtime, more costs get incorporated.

iv. Discount from Charges that get billed.

It gives the provider the least risk level where the payer agrees to reimburse at a discount that is negotiated by use of the providers’ standard that serves in billing and tracking usage/activity.

Question 3

Diagnosis code is explained as the translation of descriptions in writing form of injuries, illnesses and diseases into codes from a certain cataloguing. Also, it is an amalgamation of numbers and letters that are assigned to a distinct procedure, symptom or diagnosis (Tsai & Taylor, 2018). When classifying healthcare, these codes get used beside the intervention codes as a segment of the coding process clinically. Despite being somewhat complex, the diagnosis code permits for information rationalization which is needed by hundreds of individuals. Also, it gives room for a universal unification of medical statistics.

CPT, also known as Current Procedural Terminology is a set of medical codes which gets used to report diagnostic, surgical and medical services and procedures to individuals like accreditation organizations and companies dealing with health insurance. HCPCS, also known as Healthcare Common Procedure Coding System is used mainly for identifying services, supplies and products which are not comprised in the CPT-4 codes.

References

E. H. Bradley and L. A. Taylor, The American Health Care Paradox: Why Spending More Is Getting Us Less (New York: Public Affairs, 2013).

Glaser, William A., PhD, "Universal Health Insurance That Really Works: Foreign Lessons for the United States," Journal of Health Politics, Policy and Law, Fall 2013, pp 695-721; "Letters," Health Affairs, Fall, 2013, p 277; and "The United States Needs a Health System Like Other Countries," JAMA, August 25, 2013, pp 980-984.

Tsai, G., & Taylor, D. H. (2018). Advance care planning in Medicare: an early look at the impact of new reimbursement on billing and clinical practice. BMJ supportive & palliative care, 8(1), 49-52.

Upadhyay, U. D., Desai, S., Zlidar, V., Weitz, T. A., Grossman, D., Anderson, P., & Taylor, D. (2015). Incidence of emergency department visits and complications after abortion. Obstetrics & Gynecology, 125(1), 175-183.