Question

Managed care is a system of health care delivery that aims to provide a generalized structure and focus when managing the use, access, cost, quality, and effectiveness of health care services. There are various ways in which the managed care organization reimburses hospitals for their services. Examples of Managed Care Reimbursement Methods include the following:

• Percent-of-charge payment
• Per diem payment
• Case rate payment (DRGs and MS-DRGs)
• Ambulatory Patient Grouper (APG)
• Ambulatory Payment Classification (APCs)
• Other types of reimbursement (carve-out, stop-loss, and withhold pools)
• Please use your own words and do not copy another source.

Answer 1

Managed care is a system of health Care delivery that aims to provide a generalized structure and focus when managing the use ,access, cost,quality and effectiveness of health care services.

In which the managed care organization reimburses hospital for their services.

This is the form of reimbursement that the CMS uses to pay hospitals for medicare and medicaid recipients.also used by a few states for all payers and by many private health plans (usually non- HMO) for contracting purposes.fee for service (FFS) prividers are paid for each service performed as opposed to capitation.

Percent of charges payment: A while not as prevalent as it was in the past ,the percent of charges method is a reimbursement approach commonly used by non governmental payers to compensate hospitals and other facilities.the formula is simple.the total charges reported on the claim are multiplied by the contacted percentage.

Per diem payment: A per Diem payment version of a prospective payment system is where the insurance provider pays for the patient's healthcare based on the number of days the patient directly receives treatment from the health care provider.

DRGs and MS- DRGs

A diagnosis related group( DRG) is a patient classification system that standardizes prospective payment to hospital and encourages cost containment initiatives.in general a DRG payment covers all charges associated with an inpatient stay from the time of admission to discharge.DRG system split to become the all patient DRG system which incorperates billing for non medicare patients and the ( MS- DRG) system which sets billing for medicare patients.the MS- DRG is the most widely used system today because of the growing numbers of medicare patients.

Ambulatory patient group (APG) is a classification system for outpatient services reimbursement developed for the american medicare service by the health Care financing administration.the APG system is similar to the diagnosis related groups (DRG) which apply to inpatient care rendered by a hospital.

Carve out:carve outs occur when a payer separates services from their plan essentially carving them out from that payers coverage.carve. outs typically occurs as a way to reduce costs or increase revenue.the insurance company may pay those services at a reduced rate or not at all.

that Portion of a provider bill denied for payment (for eg, by an insurer). The term may be modified by a time period (for example day c), for a Sunday when no diagnostic or specific therapeutic activities were undertaken for a hospitalized patient..

Stop- loss: insurance is provided on a reimbursement basis.the employer is responsible for payment of all losses under a self funded plan.with the purchase of stop loss coverage,the employer is still responsible for all losses including those that exceed the deductible.

Withhold pool; under a withhold arrangement ,the health plan retains or withholds a portion of the payments that are contractually due you and other participants.these withhold amounts are then placed in one or more risk pool funds held by the health plan.the health plan may also contribute funds to the risk pool.