To Descripe The Reimbursement Model Of The US Healthcare Market?

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To descripe the reimbursement model for todays US healthcare market is to say it is fragmented and complicated. The government accounts for 64% of the US healthcare market, followed by private insurance companies, and self-pay (Self-funded plans, or cash). This fragmentation causes a lot of confusion, as each plan can have many different payment systems within itself. To review all the different ways healthcare services are paid will take alot more then a few paragraphs. Private payors have contracts with employers and with providers. Each plan can be different in the payment of services. In my personel experience, contract especially at truma hospitals are typically based on % of charges. Lets dive deeper into the the Government’s…show more content…
APC can includes all procudures that are simlar in cost. Each APC has payment indicator and status indicator. The indicators identify seperate payments, bundled payments, and drug and biologics pass-thru payments. The APC including the payment indicator and status indicator can be found on CMS website under Addundem B. (CMS, CMS.gov) https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalOutpatientPPS/Addendum-A-and-Addendum-B-Updates.html Finally, the Diagnois-Related Grouping system, which classifies an inpatient stay iinto groups for the purposes of payment. DRG payments are based off perspective payments. The perspective cost is based of a set of attriubtes with include Prinicipal diagnois, specific secondary diagoies, procedures, and discharge status. Each DRG then has three levels fo serverity that is based off the secondary diagnois, The level of serverity will increase payments. Th three levels are the following: 1) MCC–Major Complication/Comorbidity reflects the highest level of severity 2) CC–Complication/Comorbidity is the next level of severity 3) Non-CC–Non-Complication/Comorbidity does not significantly affect severity of illness and resource used. (CMS, DRG) Since DRG are based on diagnosis it is imperative that Hospitals have skilled coders, Hospitals can not afford to use any unspecificed codes or non specific codes, as the payment on those DRGs will not reflect the actual services that were performed. This is an

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