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H I4 10-4 : D ete rm in e a ppro pria te c a lc u la tio ns u se d fo r u tiliz a tio n m anagem ent a n In str u ctio ns:

C oncep t t o C onsid er:

Im agin e y o u a re th e m edic a l c o der a t y o ur lo ca l h osp it a l. It h as ju st b een a nnoun A ccre dit a tio n o f H ealt h ca re O rg aniz a tio ns (J C AH O ) is g oin g to e va lu ate th e a m b re im burs e m ent s yste m s.

Y ou h ave b een a ske d to p re pare a p re se nta tio n to th e a ccre dit a tio n c o m mit te e a th e h ealt h ca re p ro vid ers a bout th e r e im burs e m ent r a te s. In p re para tio n fo r th e d in fo rm atio n in y o ur te xt, s u pple m en ta l r e adin g in clu din g th e “ to olk it ,” a nd a va ila b in fo rm atio n.

P erfo rm a s e arc h o n h ealt h in su ra nce p olic ie s a nd r e vie w th e te xtb ook to a nsw e Pre pare 2 –3 p ara gra phs fo r e ach q uestio n. T he p aper s h ould in clu de th e fo ll o w i D ocu m en t:

T hir d p arty p aye rs h ave a dopte d M edic a re ’s r e so urc e -b ase d r e la tiv e v a lu e s ca le t h e R BR VS h as b een s u ggeste d a s a w ay to a naly ze p ro ductiv it y a nd h ealt h ca re a l. 2 004; R ota riu s a nd L ib erm an 2 00 1).

A le xa ndra ki a nd c o lle agues u se d th e R BR VS to a naly ze a nd c o m pare th e p ro du a nd a h osp it a lis t- b ase d s e rv ic e ( A le xa ndra ki e t a l. 2 009, 8 1). A r e sid ent- s ta ff e d te ach in g s e rv ic e u se s r e sid ents to m anage th e c a re o f p atie nts .

m edic a l s ch ool a nd in te rn sh ip a nd a re n ow r e ce iv in g a dva nce d tr a in in g in a s p ec d erm ato lo gy, o r p edia tr ic s. A h osp it a lis t- b ase d s e rv ic e u se s h osp it a lis ts to m ana p hysic ia n who sp ecia liz e s in managin g th e ca re ofh osp it a lin patie nts A ssig nm en t D eta ils H I4 1 0 A dvan ce d R eim burs e m en t M eth o do lo gy C B 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 2/7 physic ia n w ho s p ecia liz e s in m anagin g th e c a re o f h osp it a l in patie nts .

A cco rd in g to th e s tu die s th at A le xa n dra ki a nd c o lle agues r e vie w ed, th e tw o s e rv S im ila r in te rm s o f q ualit y o f c a re , s u ch a s m orta lit y r a te s, n oso co m ia l in fe cti h osp it a l D if f e re nt in te rm s o f a dm in is tr a tiv e m easu re s w it h h osp it a lis t- b ase d s e rv ic e s h osp it a l e xp ense s ( A le xa ndra ki e t a l. 2 009, 8 1). H ow eve r, A le xa ndra ki a nd h er c o lle agues n ote d th at th ere w as th e la ck o f r e se a th e tw o s e rv ic e s ( A le xa ndra ki e t a l. 2 009, 8 1). T o b egin to a ddre ss th is d efic it , th p ro ductiv it y u sin g th e r e la tiv e v a lu e u nit ( R VU ) o f th e R BR VS a s th e in dic a to r o f K ey d ata in th eir in ve stig atio n w ere R VU s fo r r e le va nt C PT c o des C harg es fr o m p ra ctic e b illin g r e co rd s To ta l R VU s g enera te d p er u nit o f e nco unte r ( in it ia l a nd s u bse quent h osp it a l v T o ta l R VU s g enera te d p er c lin ic a l fu ll- tim e e quiv a le nt ( F TE ) ( re sid ent o r h osp L ength o f s ta y C ase -m ix in dex D ata w ere c o lle cte d o n 5 ,9 43 p atie nts d is ch arg ed d urin g th e p erio d o f th e s tu dy P atie nts a dm it te d to in te nsiv e c a re u nit s o r c o ro nary c a re u nit s w ere e xclu ded fr o v a ria bilit y in th e in te nsit y o f s e rv ic e s p ro vid ed to th ese p atie nts . T he r e se arc h ers g enera te d p er p ro vid er w ere s ig nif ic a ntly h ig her fo r th e r e sid ent- s ta ff e d te ach in g T he r e se arc h ers c o nclu ded th at th e d if f e re nce c o uld b e r e la te d to th e lo w er tim e th an h osp it a lis ts ( A le xa ndra ki e t a l. 2 009, 8 4).

F in ally , th e r e se arc h ers o bse rv e th a t th e R BR VS is a s ta ndard iz e d to ol. It c a n b e d if f e re nt e nvir o nm ents in te rm s o f h ealt h ca re o rg aniz a tio n, g eogra phic r e gio n, o r 8 4).

R ese arc h ers a ls o e xa m in ed w heth e r th e R BR VS p aym ent m eth od s u ff ic ie ntly c o te am tr e atin g p edia tr ic a m bula to ry d ia bete s p atie nts in a p edia tr ic e ndocrin olo gy re se arc h ers e xp la in ed th at a m bula to ry p edia tr ic c a re fo r d ia bete s m ell it u s h as e v T he te am c o m pris e s p edia tr ic e ndocrin olo gis ts , c e rtif ie d d ia bete s m ell it u s n urs e so cia l w ork e rs , a nd p sych olo gis ts . T he c lin ic r e ce iv e s o ne p aym ent b ase d o n th e To s tu dy th e a dequacy o f th e r e im burs e m ent fo r m ult id is cip lin ary c a re , b illin g d at th e p erio d J u ly 1 , 2 003 th ro ugh J u ne 3 0, 2 004 w ere r e vie w ed. T he r e se arc h ers f v is it s w ere fo r c a re o f d ia bete s m ellit u s. T he c lin ic fo llo w ed th e r e co m mendatio n 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 3/7 optim al c a se m anagem ent. T hese r e co m mendatio ns in clu de p atie nt a nd fa m il y e d ie t, e xe rc is e , a nd lo ng-te rm m onit o rin g. T he r e se arc h ers n ote d th at th e te le pho p artic u la rly e xp ensiv e , a lt h ough a n im porta nt c o m ponent o f c a re .

T he r e se arc h ers c a lc u la te d r e ve nue u sin g th e R BR VS m eth od. T hey fo und th at m eth od w ere s u ff ic ie nt fo r th e p hysic ia ns’ e xp ense s in th e te am a ppro ach . H ow e genera te d u nder th e R BR VS m eth od o nly c o ve re d 1 6 p erc e nt o f th e a ctu al n onp m ult id is cip lin ary m odel. T hus, th e r e im burs e m ent d oes n ot a dequate ly r e im burs e p ra ctic e e xp ense s. T he r e se arc h ers c o nclu ded th at th e m ult id is cip lin ary c a re m o Rota riu s a nd L ib erm an c o nclu ded th at a naly sis u sin g th e R BR VS p ro vid es v a lu a in clu de: F ulf illm ent o f c o ntr a ctu al p aym ent r a te s b y h ealt h ca re in su ra nce p la ns P ro fit a bilit y o f s p ecif ic p ro ce dure s O ptim al m ix o f p hysic ia n s p ecia lt ie s P ro je ctio ns fo r c o ntr a ct n egotia tio n s T here fo re , a naly sis u sin g th e R BR VS is a m eans o f p ro ductiv it y a sse ssm ent, fin A s tu dent in a h ealt h s e rv ic e s m anagem ent ( H SM ) a ca dem ic p ro gra m w as s e rv i stu dent h ad r e ad th e p re vio us a rtic le s a bout th e p ote ntia l fo r in su ff ic ie nt r e im burs T he H SM in te rn d ecid ed to a naly ze th e fin ancia l v ia bilit y o f th e p ra ctic e . T he in te A NY Y EA R: P ro je cte d R even ue b y C PT ® V is it C ode* W ork R VU N on- Fac P E R VU M P RVU To t R VU (C ol B + C ol C + C ol D ) Co It e m $ 99202-O ff ic e V is it , N ew , Str a ig htfo rw ard 0 .8 8 0.7 9 0.0 5 1.7 2 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 4/7 Str a ig htfo rw ard M edic a l D ecis io n M akin g 99203-O ff ic e V is it , N ew , L ow C om ple xit y M edic a l D ecis io n M akin g 1.3 4 1.1 3 0.0 9 2.5 6 9 9204-O ff ic e V is it , N ew , M odera te C om ple xit y M edic a l D ecis io n M akin g 2.0 0 1.5 0 0.1 2 3.6 2 9 9205-O ff ic e V is it , N ew , H ig h C om ple xit y M edic a l D ecis io n M akin g 2.6 7 1.7 8 0.1 5 4.6 0 9 9211 -O ff ic e V is it , E st., M ay N ot R equir e P re se nce o f P hysic ia n 0.1 7 0.3 9 0.0 1 0.5 7 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 5/7 99212-O ff ic e V is it , E st., S tr a ig htfo rw ard M edic a l D ecis io n M akin g 0.4 5 0.5 4 0.0 3 1.0 2 9 9213-O ff ic e V is it , E st., L ow C om ple xit y M edic a l D ecis io n M akin g 0.6 7 0.6 9 0.0 3 1.3 9 9 9214-O ff ic e V is it , E st., M odera te C om ple xit y M edic a l D ecis io n M akin g 1.1 0 1.0 3 0.0 5 2.1 8 9 9215-O ff ic e V is it , E st., H ig h C om ple xit y M edic a l D ecis io n M akin g 1.7 7 1.3 2 0.0 8 3.1 7 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 6/7 A ll P hysic ia ns’ C urre nt P ro ce dura l T e rm in olo gy® ( C PT® ) fiv e -d ig it n um eric c o de in str u ctio ns, g uid elin es, a nd o th er m ate ria ls a re c o pyrig hte d b y th e A m eric a n M e * V alu es a re r e pre se nta tiv e o nly ; r e aders a re c a utio ned to c h eck c u rre nt F edera Q uestio ns P re p are 2 –3 p ara g ra p hs f o r e ach q uestio n:

1. W hat r e aso ns c o uld a cco unt fo r th e g ap b etw een th e r e im burs e m ent fo r m ult id m ult id is cip lin ary c a re ? 2. In e va lu atin g th e R BR VS r e im burs e m ents fo r th e p hysic ia n p ra ctic e , w hat o th e n ote s th at c o de 9 9205 h as th e h ig hest R VU . E xp la in w heth er th e in te rn s h ould p atie nts ( o ff ic e v is it , n ew p atie nt, h ig h c o m ple xit y ). 3. D escrib e th e e le m ents o f th e o utp atie nt a nd in patie nt p ro sp ectiv e p aym ent s ys 4. W hy d oes th e IP F P PS le ngth -o f- s ta y a dju stm ent fa cto r g ro w s m alle r d urin g th 5. D escrib e a t le ast tw o o f th e p atie nt- le ve l a dju stm ents fo r IP F P PS c la im s a nd w 6. E nvis io n g ove rn m enta l in vo lv e m ent a nd in ce ntiv e in it ia tiv e s fo r p ro vid in g c o st Y o ur s u bm is sio n s h ould :

1. C re ate a b ib lio gra phy c it in g a m in im um o f th re e r e fe re nce s a cco rd in g to A PA f 2. R eso urc e s c a n in clu de y o ur te xt a nd c h apte r r e fe re nce s, o rg aniz a tio nal w ebsi A sso cia tio n, A m eric a n H osp it a l A sso cia tio n, o r th e A m eric a n H ealt h In fo rm atio 3. T he p aper s h ould b e a t le ast 2 –3 p ara gra phs in le ngth fo r e ach q uestio n ( n ot i 4. T he p aper s h ould fo llo w th e c o nve ntio ns o f S ta ndard A m eric a n E nglis h ( c o rre c 5. Y our w rit in g s h ould b e w ell o rd ere d, lo gic a l, a nd u nif ie d, a s w ell a s o rig in al a nd co nte nt, o rg aniz a tio n, s ty le , a nd m ech anic s. 6. Y ou s h ould c it e s o urc e s u sin g A PA fo rm at. 7. P re se nta tio n m ust b e p ro fe ssio nally a ttr a ctiv e . Im porta n t: P le ase b e s u re to v is it A ca dem ic S ucce ss C ente r: W rit in g C ente r to th is A ssig nm ent.

S ubm it tin g y o ur w ork :

P ut y o ur r e sp onse s in a W ord d ocu m ent. Y our ta ble o r g ra ph m ay b e c o pie d a nd su bm it te d s e para te ly . S ubm it y o ur w ork to th e a ppro pria te D ro pbox.

G ra d in g C rit e ria : 11/1/2020 Unit 7 Assignment - HI410 Advanced Reimbursement Methodology https://purdueglobal.brightspace.com/d2l/le/content/143224/viewContent/10715241/V iew 7/7 Refle ct i n e P ortfo li o D ow nlo ad P rin t B e s u re to r e vie w th e g ra din g r u bric fo r th is A ssig nm ent. T a sk : V ie w t h is t o pic A ctiv it y D eta ils