Discussion 1-2

Consider the following scenario:

Derek Gonsalez is a 64-year-old man who has had several problems with his knees. Derek has sought many treatments in an effort to reduce the inflammation in his knees, and his doctors have determined that he is a good candidate for a full knee replacement. Derek starts out by attending a pre-operative visit with his orthopedic surgeon where he schedules his surgery and obtains instructions for his surgery. On his surgery day, Derek is admitted to the hospital. He stays there for several days after his knees are replaced. After being discharged, Derek is given pain medication and a referral for 6–8 weeks of physical therapy.

Depending on the type of insurance and the healthcare organizations involved in this scenario, the claim(s) could be reimbursed “prospectively” or “retrospectively.”

Reimbursement methodology involves quite a few terms, concepts, and computations. It can be challenging to keep all of the similar sounding variables straight. However, as a healthcare professional, you need to be aware of these terms and concepts and have a basic understanding of how reimbursement is determined.

This week, you will choose a payment system, analyze how the system determines reimbursement, and determine the benefits and drawbacks of the system. In addition, you will analyze a case study and propose an action plan to eliminate errors in reimbursement.

Discussion: Prospective Payment Systems

Consider the case of Derek Gonsalez in this week’s Introduction. In this case, rather than the hospital getting paid for each supply and service used during the hospital stay, the payer will likely pay a lump sum for the “bundled” knee replacement. If the paid amount is less than the cost, the hospital will have to cover the additional cost. If the amount paid is more than what Derek’s services cost, the hospital keeps the savings. The amount paid is based on the prospective payment system (PPS) used and the service that is rendered. (Farlex, 2016)

In this Discussion, you analyze a prospective payment system. You consider the benefits and drawbacks of the system and discuss the associated concepts.

References:

Farlex. (2018). Prospective payment system. (2018). In The Free Dictionary. Retrieved from https://medical-dictionary.thefreedictionary.com/prospective+payment+system

To prepare for this Discussion:

• Review this week’s Learning Resources.

• Choose one of the following topics on which to focus for this Discussion:

◦ Acute care PPS

◦ Skilled nursing facility PPS

◦ Inpatient rehabilitation facility PPS

◦ Inpatient facility PPS

◦ Inpatient psychiatric PPS

◦ Hospital outpatient PPS

◦ Ambulatory surgical center PPS

By Day 4

Post a comprehensive response to the following:

• Summarize the payment system including reimbursement concepts (e.g., diagnostic related groups, discounting, outliers, etc.).

• Describe the benefits the payment system offers to healthcare organizations.

• Describe the drawbacks the payment system has for healthcare organizations.

• Detail your overall opinion of the prospective payment system. Do you think it is beneficial? Explain your response.

• Include any additional information about the payment system that would be helpful to the patient.

Provide specific examples in your response. Support your post with the Learning Resources and at least one outside scholarly source.

Read a selection of your colleagues' postings.

Required resources/Links:

https://www.acep.org/administration/reimbursement/reimbursement-faqs/apc-ambulatory-payment-classifications-faq/#sm.0001f9l2l4l9vcq3ut11ya8c4907z

https://www.micromd.com/demystifying-macra-qpp-and-mips-ebook/

https://www.nhcaa.org/resources/health-care-anti-fraud-resources/the-challenge-of-health-care-fraud.aspx