Principles of Healthcare Reimbursement and Revenue Cycle Management 7th Edition by Anne Casto, Susan White 158426800X 9781584268000
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ISBN 10: 158426800X
ISBN 13: 9781584268000
Author: Anne B. Casto, Susan White
The seventh edition of Principles of Healthcare Reimbursement and Revenue Cycle Management is a comprehensive tool for educators, students, and healthcare professionals to master understanding of the US healthcare reimbursement systems and their impact on the US healthcare delivery system and economy. Current and future healthcare professionals who desire to work in healthcare finance, revenue cycle, compliance, and coding can use this text to gain the knowledge and training they need to succeed. Key Features New Patient Connection section in each chapter guides the reader through applying chapter concepts to real-life scenarios Introduction of revenue integrity principles Expanded coverage of revenue cycle processes and audit and denials management Extensive new content for coding and clinical documentation integrity (CDI) management New chapter dedicated to revenue cycle analysis Student workbook included in online ancillaries. Instructor materials include an instructor manual, PowerPoint slides for lectures, a test bank, and a full answer key
Principles of Healthcare Reimbursement and Revenue Cycle Management 7th Table of contents:
Part I: Foundations of Healthcare Reimbursement
Chapter 1 Healthcare Reimbursement and Revenue Cycle Management
National Models of Healthcare Delivery
Healthcare Delivery in the US
Health Insurance
Historical Perspectives
Health Insurance and Employment
Third-Party Payer
Revenue Cycle Management
Revenue Integrity
Integrated Revenue Cycle
Components of the Revenue Cycle
Chapter 2 Health Insurance
Types of Health Insurance
Individual Healthcare Plans
Employer-Based Healthcare Plans
Provisions and Functions of Health Insurance Plans
Sections of a Health Insurance Policy
Definitions
Eligibility and Enrollment
Benefits
Limitations
Exclusions
Procedures
Appeals Processes
Managed Care
Benefits and Services of Managed Care
Characteristics of Managed Care
Types of Managed Care Plans
Chapter 3 Government-Sponsored Healthcare Programs
Medicare
Medicare Part A
Medicare Part B
Medicare Part C
Medicare Part D
Medicare Supplemental Insurance
Medicaid
Other Government-Sponsored Healthcare Programs
Programs of All-Inclusive Care for the Elderly
Children’s Health Insurance Program
TRICARE
Veterans Health Administration
Civilian Health and Medical Program of the Department of Veterans Affairs
Indian Health Service
Workers’ Compensation
Part II: Reimbursement Methodologies and Payment Systems
Chapter 4 Healthcare Reimbursement Methodologies
Types of Healthcare Reimbursement Methodologies
Retrospective Reimbursement
Prospective Reimbursement
Risk Adjustment Models
Accountable Care Organization
Chapter 5 Medicare Hospital Acute Inpatient Payment System
Basic Medicare Payment System Concepts
Annual Maintenance of Medicare Payment Systems
Cost Reports
Basic Medicare Value-Based Purchasing Concepts
Quality Reporting Programs
Medicare Hospital Acute Inpatient Services Payment System
Medicare Severity Diagnosis-Related Group Classification System
Payment System Provision
Payment Workflow
CMS Value-Based Purchasing Programs for the Hospital Acute Inpatient Setting
Chapter 6 Medicare Skilled Nursing Facility Services Payment System
Patient-Driven Payment Model (PDPM)
PDPM Structure
Wage Index Adjustment
Determining PDPM Reimbursement
Skilled Nursing Facility Value-Based Purchasing Program
Chapter 7 Medicare Hospital Outpatient Payment System
Reimbursement for Outpatient Hospital Services
Ambulatory Payment Classification System
OPPS Provisions
OPPS Payment Workflow
Chapter 8 Medicare Physician and Other Health Professional Payment System
Structure of Payment
Relative Value Unit and Geographic Practice Cost Index
Conversion Factor
Calculation
Medicare Physician and Other Health Professional Payment System Provisions
Clinician Type
Special Circumstances
Underserved Area
Medicare Physician and Other Health Professional Payment Workflow
Quality Payment Program
Part III: Revenue Cycle Processes
Chapter 9 Revenue Cycle Front-End Processes—Patient Engagement
Scheduling Services
Price Transparency
Prior Authorization
Patient Intake
Patient Financial Counseling
Chapter 10 Revenue Cycle Middle Processes—Resource Tracking
Charge Capture
Charge Capture Strategies
Code Sets for Diagnosis, Procedure, and Supply Reporting
The International Classification of Diseases
Healthcare Common Procedure Coding System
The Coding Process
Facility Coding
Professional Coding
Single Path Coding
Chapter 11 Revenue Cycle Back-End Processes—Claims Production and Revenue Collection
Claims Production
Claims Submission
Determining Expected Reimbursement
Adjudication
Benefits Statements
Claims Reconciliation
Collections
Part IV: Revenue Cycle Management
Chapter 12 Coding and Clinical Documentation Integrity Management
Coding Management
Staffing
Coding Tools
Performance Assessment
Coding Compliance Plan
Clinical Documentation Integrity
CDI Process
CDI Staffing
CDI Performance Assessment
CDI Program Metrics
Chapter 13 Revenue Compliance
Fraud and Abuse
Oversight of Medicare Claims Payments
Comprehensive Error Rate Testing Program
Office of Inspector General Reports
Recovery Audit Program
Nongovernment Payer Reviews
Audit Management
Coding and Billing Compliance Tools
Medicare Claims Processing Manual
CMS Transmittals
National and Local Coverage Determinations
National Correct Coding Initiative
Medicare Code Editor and Medicare Outpatient Code Editor
Payer Policy Manuals
Denials Management
Part V: Revenue Cycle Analysis
Chapter 14 Healthcare Data in Action: Real-World Analysis
Case-Mix Index Calculation
Case-Mix Index Analysis
Outpatient Service-Mix Index Analysis
MS-DRG Relationships Analysis
Site of Service Analysis: Inpatient versus Outpatient
Evaluation and Management Facility Coding in the Emergency Department
Physician Coding Analysis
Outpatient Code Editor Review for Hospital Outpatient Services
Physician Productivity Analysis
Clinical Documentation Integrity Program Analysis
Appendix A Glossary
Appendix B Answer Key for Check Your Understanding Questions
Appendix C CMS 1500 Claim Form
Appendix D CMS 1450 (UB-04) Claim Form
Appendix E Medicare Summary Notice
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