Reimbursement Methodologies Unit 6 Assignment 1

Fellow Classmates and Professor, The End Stage renal Disease (ESRD) Prospective Payment System has some very unique differences as opposed to the other PPS’s. These benefits are provided for individuals who have permanent kidney failure and require either dialysis or a kidney transplant. Coverage under this area is even further unique in that it applies to individuals of all ages. The other payment systems are based on a location where as this payment system is based on a particular condition. This system was put into place due to the amount Medicare was spending to fund treatments for individuals with ESRD. By creating a single payment system CMS is able to bundle payment for all services associated with renal dialysis treatment (Casto 2013). The resources and cost are impacted by several patient characteristics. The Patient-Level Adjustments are; patient age, body surface area, low body mass index, new patient (onset of dialysis), and specified comorbidities. The Facility-Level adjustments are wage index and low-

- After reviewing the case, I would recommend meetings with the billing staff to insure everything is being coded and billed correctly; schedule weekly meeting with surgeons/nurses to discuss the different procedures and equipment they use; and maybe make changes to the software system, possible a replacement, to ensure complete up to date financial results regarding billing. 3. Practice Assignment on Fee Calculations: (40 Points)1. Kaplan Anytown Hospital’s charges, payments, and adjustments from third-party payers for the month of July are represented in table 4-W.a.Calculate the percentage of charges, payments, and adjustments for each third-party payer and enter the percentages in the percentages columns of table 4-W (25 points) Table 4-WPayerChargesPaymentsAdjustmentChargesPaymentsAdjustmentsBC/BS$450,000$360,000$90,00023%31%12%Commercial$250,000$200,000$50,00013%17%6%Medicaid*$350,000$75,000$275,00018%6%36%Medicare$750,000$495,000$255,00038%42%33%TRICARE*$150,000$50,000$100,0008%4%13%Totals$1,950,000$1,180,000$770,000100%100%100%* Managed care capitated payment for periodb.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. -The facility does the most business with Medicare, and the least business with Tricare. c.Based on the percentages calculated in the payment column, identify the payers that reimburse the facility the most and the least. (5 pts) –Based on my calculations Medicare does the most, and Tricare does the least.

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