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This report details how U.S. hospitals are reimbursed for cardiac services by various payers, including Medicare and commercial insurance. It offers tools for cardiology managers to navigate complex healthcare reimbursement systems.
Area of Science:
- Healthcare Management
- Health Economics
- Cardiology Services
Background:
- Cardiovascular disease is the leading cause of hospitalization in the U.S., despite medical advances.
- Cardiac services represent a significant portion of inpatient care, particularly for Medicare beneficiaries.
- Effective management of cardiology programs is crucial due to the complexity and cost of cardiac care.
Purpose of the Study:
- To explain hospital reimbursement mechanisms for cardiac services in the U.S.
- To provide analytical and planning tools for hospital managers involved in cardiology reimbursement.
- To support front-line managers in coordinating services and participating in the reimbursement process.
Main Methods:
- Analysis of common reimbursement principles and practices for acute-care community hospitals.
- Description of payment systems including Medicare, Medicaid, and private insurance plans.
- Inclusion of a 'tool kit' with analytical, planning, and forecasting techniques.
Main Results:
- Hospitals utilize diverse payment mechanisms based on patient insurance (Medicare, Medicaid, private plans).
- The report outlines key components of hospital payment systems, such as ICD-9 coding, DRGs, and PPS.
- It introduces the Resource-Based Relative Value Scale (RBRVS) as a payment methodology.
Conclusions:
- Understanding reimbursement is vital for managing cardiology programs effectively.
- The report serves as a resource for hospital managers, finance, and accounting personnel.
- Data and analytical tools provided can aid in strategic planning and financial forecasting for cardiac services.
Abstract:
This report describes how acute-care community hospitals in the United States get paid for services when their patients either are entitled to Medicare or Medicaid benefits or subscribe to a Blue Cross or Blue Shield plan, a commercial insurance plan, a health maintenance organization, a preferred provider organization, or some other third-party payment mechanism. The focus of this report is on cardiac services, which are the most common type of inpatient services provided by acute-care community hospitals. Over the past three decades, extraordinary advances in medical and surgical technologies as well as healthier life-styles have cut the annual death rate for coronary heart disease in half. Despite this progress, cardiovascular disease remains the number one cause of hospitalization. On average nationwide, diseases and disorders of the circulatory system are the primary reason for 17 percent of all patient admissions, and among the nation's 35 million Medicare beneficiaries they are the primary reason for 25 percent of all admissions. In the United States heart disease is the leading cause of death and a major cause of morbidity. Its diagnosis and treatment are often complex and costly, often requiring multiple hospitalizations and years of medical management. To focus management attention and resources on the immense cardiology marketplace, many hospitals have hired individuals with strong clinical backgrounds to manage their cardiology programs. These "front-line" managers play a key role in coordinating a hospital's services for patients with cardiovascular disease. Increasingly, these managers are being asked to become active participants in the reimbursement process. This report was designed to meet their needs. Because this report describes common reimbursement principles and practices applicable to all areas of hospital management and because it provides a "tool kit" of analytical, planning, and forecasting techniques, it could also be useful to hospital marketing, planning, finance, and accounting personnel. In addition, the rich reservoir of data contained in the appendixes to this report may be of interest to hospital chief executive officers, cardiologists, and cardiovascular surgeons. In addition to the introduction and summary sections, this report contains five main sections. Sequentially, these deal with: the ways hospitals get paid for what they do; ICD-9 coding DRGs, PPS, and Medicare claims administration; ways to analyze how well your hospital is doing; planning and forecasting; the new Resource-Based Relative Value Scale.(ABSTRACT TRUNCATED AT 400 WORDS)