Homework: Paying for Hospital and Physician Services
Overview
Third-party payers are the insurers that reimburse physicians and health care systems for services rendered - which identifies them as a central source of revenue for physicians and health care systems. This includes the two main categories of payers: the private insurances (such as Blue Cross/Blue Shield, etc.), and the public/government programs (such as Medicare/Medicaid/SCHIPs).
Third-party payers use a variety of reimbursement methods to pay providers and hospitals, depending on the specific payer involved and also the specific service(s) provided (outpatient or inpatient). The calculations vary and can be complicated, but they are critical to understand in terms of the basic math behind them. It's also important to understand how the different payers compare in terms of reimbursement levels. Let's move forward to examine how services are paid for by the third-party payers.
Case Homework
Using the information in the Module overview and required readings, as well as some additional research in peer-reviewed sources, complete your Case homework by answering the questions in the following two-part homework. Please show all formulas and calculations of your work in your paper.
Part I: Paying for Hospital Services- Overview
Mrs. Jones is a 74-year-old woman who is currently hospitalized for an ischemic stroke. She's at a large urban Philadelphia hospital, and in the past few days, she's incurred $189,000 in Medicare-approved charges for her care. Using the information provided in this Module, as well as the Hospital Payments Example (found in the Course's table of contents link under "Presentations"), use the DRG table below to answer the following questions. Be sure to include all formulas and calculations used in your paper.
DRG
Description
Case Weight
163.3
Ischemic stroke
2.0150
338.0
Appendix removal
1.8911
870.1
Septicemia/severe sepsis
4.3296
Part 1: Task
In approximately three pages, answer the following questions related to Mrs. Jones' ischemic stroke. Show all formulas and calculations of your work.
A. What is the operating payment to be paid to the hospital?
B. What is the capital payment to be paid to the hospital?
C. Will the hospital be eligible for the Medicare outlier payment for this patient?
D. What is the total payment due to the hospital?
Part 2: Paying for Physician Services - Overview
Mr. Thompson is an 83-year-old Medicare beneficiary. He is under the care of Dr. Heintz. Assume the following values for services provided by Dr. Heintz:
Categories
RVU
Geographic Cost Index
Product
Work 28.16 1.371 24.35
Practice Expense 37.47 1.925 68.08
Malpractice 11.49 0.668 4.24
Conversion Factor: 51.52
Part 2: Task
In approximately three pages, answer the following questions. Show all formulas and calculations of your work.
A. How much will Medicare pay Dr. Heintz if he is a Medicare participating physician? How much out-of-pocket payment will Mr. Thompson be responsible for?
B. How much will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who elects homework? How much out-of-pocket payment will Mr. Thompson be responsible for?
C. How much will Medicare pay Dr. Heintz if he is a Medicare non-participating physician who does not elect homework? How much out-of-pocket payment will Mr. Thompson be responsible for?
Format your homework according to the give formatting requirements:
1. The answer must be double spaced, typed, using Times New Roman font (size 12), with one-inch margins on all sides.
2. The response also includes a cover page containing the title of the homework, the course title, the student's name, and the date. The cover page is not included in the required page length.
3. Also include a reference page. The references and Citations should follow APA format. The reference page is not included in the required page length.