Group 1: Chapter 7 - Reimbursement Methodologies

For each inappropriate charge, what report in the patient record would the third-party payer representative review to justify denial of reimbursement?We want to know if there are problems in reimbursement, where would we be able to investigate that in the patient record to find discrepancies?

1. Duplicate charges (for example, multiple charges for same service, such as surgery)

2. Laboratory panel tests for which there should be a single charge

3. Medications and diagnostic tests not prescribed by a physician

4. Medications that a patient did not receive

5. Tests repeated because of hospital error.

6. Services listed for dates after the patient was discharged from the facility

7. Professional services performed by nurses or technicians (for example, equipment monitoring)

Group 2

Alfred State Medical Centers charges, payments, and adjustments from third-party payers for the month of July are represented in table W7.1

a. Calculate the percentage of charges, payments, and adjustments for each third-party payer and enter the percentages in the percentages columns of table W7.1.

Table W7.1

Payer	Charges	Payments	Adjustment	Charges	Payments	Adjustments
BC/BS	$450,000	$360,000	$90,000	23%	?	?
Commercial	$250,000	$200,000	$50,000		17%	6%
Medicaid*	$350,000	$75,000	$275,000	18%	?	?
Medicare	$750,000	$495,000	$255,000	?	42%	33%
TRICARE*	$150,000	$50,000	$100,000	?	?	?
Totals	$1,950,000	$1,180,000	$770,000	100%	100%	100%

b. Based on the percentages calculated in the charges column, identify the payer the facility does the most business with and the payer it does the least business with.

c. Based on the percentages calculated in the payment column, identify the payers that reimburse the facility the most and the least.

d. Based on the percentages calculated in the adjustments column, identify the payers that proportionately reimburse the facility the most and the least.