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5 pages/β‰ˆ1375 words
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Style:
APA
Subject:
Health, Medicine, Nursing
Type:
Case Study
Language:
English (U.S.)
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Total cost:
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Topic:

Paying for Hospital and Physician Service: Fees and Eligibilities

Case Study Instructions:

Third-party payers are the insurers that reimburse physicians and health care systems for services rendered – which identifies them as a central source of revenue for physicians and health care systems. This includes the two main categories of payers: the private insurances (such as Blue Cross/Blue Shield, etc.), and the public/government programs (such as Medicare/Medicaid/SCHIPs).
Third-party payers use a variety of reimbursement methods to pay providers and hospitals, depending on the specific payer involved and also the specific service(s) provided (outpatient or inpatient). The calculations vary and can be complicated, but they are critical to understand in terms of the basic math behind them. It’s also important to understand how the different payers compare in terms of reimbursement levels. Let’s move forward to examine how services are paid for by the third-party payers.
Case Assignment

Using the information in the Module 4 overview and required readings, as well as some additional research in peer-reviewed sources, complete your Case assignment by answering the questions in the following two-part assignment. Please show all formulas and calculations of your work in your paper.
Part I - Paying for Hospital Services – Overview Also review the complete M4- Case assignment instructions uploaded. The sample of the chart is included in the instructions. This is a complex assignment, therefore I'm given you plenty of time. The chart must be included in your final paper. Follow all instructions and cite the arthors work to gain all points.
Mrs. Jones is a 74-year-old woman who is currently hospitalized for an ischemic stroke. She’s at a large urban Philadelphia hospital, and in the past few days, she’s incurred $189,000 in Medicare-approved charges for her care. Using the information provided in this Module, as well as the Hospital Payments Example (found in the Course’s table of contents link under “Presentations”), use the DRG table below to answer the following questions. Be sure to include all formulas and calculations used in your paper.
DRG Description Case Weight
163.3 Ischemic stroke 2.0150
338.0 Appendix removal 1.8911
870.1 Septicemia/severe sepsis 4.3296
Part I – Assignment
In approximately three pages, answer the following questions related to Mrs. Jones’ ischemic stroke. Show all formulas and calculations of your work.
1. What is the operating payment to be paid to the hospital?
2. What is the capital payment to be paid to the hospital?
3. Will the hospital be eligible for the Medicare outlier payment for this patient?
4. What is the total payment due to the hospital?
Part II – Paying for Physician Services – Overview
Mr. Tompson is an 83-year-old Medicare beneficiary. He is under the care of Dr. Heintz. Assume the following values for services provided by Dr. Heintz:
Categories RVU Geographic Cost Index Product
Work 28.16 1.371 24.35
Practice Expense 37.47 1.925 68.08
Malpractice 11.49 0.668 4.24
Conversion Factor: 51.52
Part II – Assignment
In approximately three pages, answer the following questions. Show all formulas and calculations of your work.
1. How much will Medicare pay Dr. Heintz if he is a Medicare participating physician? How much out-of-pocket payment will Mr. Thompson be responsible for?
2. Howmuch will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who elects assignment? How much out-of-pocket payment will Mr. Thompson be responsible for?
3. How much will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who does not elect assignment? How much out-of-pocket payment will Mr. Thompson be responsible for?
Assignment Expectations
1. Conduct additional research to gather sufficient information to support your analysis.
2. Provide a response of 5 pages, not including title page and references. It is required that you show the formulas and calculations performed to arrive at your answers.
3. There are multiple required items to be addressed herein; please use subheadings to show where you are responding to each required item and to ensure that none are omitted.
4. Support your paper with peer-reviewed articles, with at least 3 references. Use the following link for additional information on how to recognize peer-reviewed journals:
Angelo State University Library. (n.d.). Library Guides: How to recognize peer-reviewed (refereed) journals. Retrieved from https://www(dot)angelo(dot)edu/services/library/handouts/peerrev.php
5. You may use the following source to assist in formatting your assignment:
Purdue Online Writing Lab. (n.d.). General APA

Case Study Sample Content Preview:

Paying for Hospital and Physician Service
Student’s Name
Department, University
Course Code: Course Name
Professor
Due Date
Paying for Hospital and Physician Service
Part I: Paying for Hospital Services
DRG

Description

Case Weight

163.3

Ischemic stroke

2.0150

338.0

Appendix removal

1.8911

870.1

Septicemia/severe sepsis

4.3296

As with the case of Mrs. Jones, when it comes to paying for hospital services for patients under Medicare coverage, the PPS (prospective payment system) comes to play for the approved charges in regard to the distinctive nature of the care provided. The use of the PPS has tremendously delivered real significant changes in the U.S. health care industry, specifically in relation to the ways of the utilization of clinic administrations in different hospitals by the doctors when offering professional care services to their respective patients (Centers for Medicare and Medicaid Services, 2019a). As one of the strategies in healthcare facilities where doctors offer their professional services that have taken a toll on regulations, PPS fosters the rates of setting suitable rules that are unquestionably all-round respected. The system primarily facilitates the incorporation of managed costs as opposed to the predominant market powers, national-based rates as opposed to the particular rates for the healthcare organizations, and installments for each unit as opposed to everyday installments per benefit. However, the execution of the PPS has been controversial as some are promoters while others are doubters of the system (Centers for Medicare and Medicaid Services, 2019a). Notably, the proponents of the PPS based their fundamental trust on the consideration that the system would result in a decrease in installments. The reduction in installments would be fundamentally coordinated by much lower spending levels (Kaiser Family Foundation, 2019). The lower spending levels are attained through the lessened duration of hospital stay, more productive and quality clinical operations devoid of medical errors, and diminished force of care to eliminate unnecessary tests.
Operating Payment for the Hospital
The operating payment is often paid as a working installment to sustain the daily operations and activities of the hospital in delivering the care services (Centers for Medicare and Medicaid Services, 2019b). In determining the operating payment that ought to be made to the given hospital, the specific utilization of the working estimations and equations of a substantial urban clinic like Mrs. Jones got hospitalized in Philadelphia is considered. Based on this consideration, since Mrs. Jones was hospitalized for an Ischemic stroke and upon reviewing the complete M4-Case chart, it is possible to figure out that the working installment upon which operating payment to be made to the hospital for a DRG 163.3 is 2.0150 X (($5,479 X 1.4551) + ($1,756.89 x 1)) x (1+ 0.0834 + 1.9010). To begin with, we increase the 5,479 X 1.4551 = 7,972.4929, then 1,756.89 x 1= 1,756.89, then (1+ 0.0834 + 1.9010 = 2.9844. Presently the issue will be 2.0150 X (7,972.4929 + 1,756.89) x (2.9844), here we include 7,972.4929 + 1,756.8...
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