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SV-Financing-Reimbursement.pptxHSMP 3200
Financing Health Services Reimbursement
Cost of health services is out of control
Constantly increasing
The cost of health care in the United States is the highest in the world (yet the quality our outcomes is not the best).
Nationally, health related expenses account for 18% of the total value of all products and services produced in the U.S. (This is called Gross Domestic Product or GDP).
Attempts to address the high cost of health care result in constantly changing reimbursement models . These changes usually increase the administrative cost of health care delivery.
“Reimbursement”
In health services terminology payment received for services provided is referred to as
Reimbursement
In other words, reimbursement is the health administration term for payment. In healthcare the source of reimbursement is called a “Payor” …notice the different spelling (usually it would be spelled “Payer”)
Who pays?
Public versus Private
Private reimbursement sources
This includes reimbursement/payment received directly from the patient. This is often referred to as “out of pocket”.
Private pay also includes reimbursement from commercial health insurance payors (*)
We distinguish between “commercial” and non-commercial payors. Commercial generally refers to insurance payors such as Blue Cross, Aetna, Cigna and others. Non-commercial generally refer to government/entitlement plans such as Medicare, Medicaid/Tenncare, Tricare and “public” health plans.
Public reimbursement sources [Three of the largest ones]
Medicare is a Federally funded health insurance program for citizens age 65 or older or any age with end stage renal disease.
Medicaid is a State and Federally funded health insurance program for low income individuals and families. In Tennessee this program is called TENNCARE.
TRICARE is a federally funded health insurance plan provided to active duty, reserve, and retired military personnel and their dependants.
Physician reimbursement Resource-Based Relative Value Scale (RBRVS)
Resource-Based Relative Value Scale (RBRVS) is the methodology used to determine how much money medical providers should be paid. It is currently used by Medicare and by nearly all managed care health insurance plans (HMOs, PPOs) in the United States.
RBRVS determines reimbursement paid the provider based on three separate factors: physician work (52%), practice expense (44%), and malpractice insurance expense (4%).
Skilled, long term care reimbursement Resource Utilization Groups (RUGS)
Resource Utilization Groups (RUG)
The RUGs are measures of staffing intensity and are used to categorize long term care residents for Medicare payment under what is called the skilled nursing facility prospective payment system.
FYI:
Skilled Nursing Facility (SNF) is health care service approved by Medicare and Medicaid or accredited by the Joint Commission that is primarily engaged in providing inpatient skilled nursing care or rehabilitation services for injured, disabled or sick persons.
This is also called an Extended Care Facility.
“Skilled” nursing simply refers to is a level of nursing care more intensive and for a longer period than general hospital nursing care.
So, what do you do?
Few disagree that the ever increasing cost of the U.S. healthcare system must be “contained”. How to do this is the basis for the “Healthcare reform” debate that has been very intense in recent years.
As a healthcare professional you should be an informed and vocal part of this debate. After all, you are the experts.
