INSTITUTIONAL PROVIDERS. Hospitals For most Inpatient medical and surgical Covered Services, Hospitals are paid per diem rates, which are specific amounts paid for each day a Member is in the Hospital. These rates usually vary according to the intensity of services provided and do not typically include any payment for professional (e.g., physician/surgeon) charges or expenses. Some Hospitals are also paid case rates, which are set dollar amounts paid for a complete Hospital stay related to a specific procedure or diagnosis, (e.g., transplants). For most outpatient and Emergency Covered Services and procedures, most Hospitals are paid specific rates based on the type of service performed. Hospitals may also be paid a global rate for certain outpatient Covered Services (e.g., lab and radiology) that includes both the Facility (or a technical charge) and Physician payment. For a few Covered Services, Hospitals are paid based on a percentage of their billed charges. Most Hospitals are paid through some combination of the above payment mechanisms for various Covered Services. Some Hospitals participate in a quality incentive program. The program provides increased reimbursement to these Hospitals when they meet specific quality and other criteria, including "Patient Safety Measures". Such patient safety measures may include and are consistent with recommendations by CMS, The Leap Frog Group, Joint Commission on Accreditation of Health care Organizations (JCAHO), and the Agency for Health Care Research and Quality (AHRQ). The quality criteria are designed to help reduce medical and medication errors. Other criteria are directed at improved patient outcomes and electronic claim and record submissions. Use of these types of incentives is expected to evolve over time. Skilled Nursing Homes, Rehabilitation Hospitals, and other care facilities Most Skilled Nursing Facilities and other special care facilities are paid per diem rates, which are specific amounts paid for each day a Member is in the facility and do not typically include any payment to the facility for professional (e.g., physician) charges or expenses. These amounts may vary according to the intensity of services provided. Ambulatory Surgical Centers (ASCs) Most ASCs are paid specific rates based on the type of service performed. For a few Covered Services, some ASCs are paid based on a percentage of its billed charges. Ancillary Service Providers Some ancillary service providers, such as Durable Medical Equipment and Home Healt...
INSTITUTIONAL PROVIDERS. Hospitals: For most Inpatient medical and surgical services, Hospitals are paid per diem rates, which are specific amounts paid for each day a Covered Person is in the Hospital. These rates usually vary according to the intensity of the Covered Services provided. Some Hospitals are also paid case rates, which are set dollar amounts paid for a complete Hospital stay related to a specific procedure or diagnosis, e.g., transplants. For most Outpatient and Emergency Services and procedures, most Hospitals are paid specific rates based on the type of Covered Service performed. For a few Covered Services, Hospitals are paid based on a percentage of billed charges. Most Hospitals are paid through a combination of the above payment mechanisms for various services. The Carrier implemented a quality incentive program with a few Hospitals. This program provides increased reimbursement to these Hospitals based on them meeting specific quality criteria, including “Patient Safety Measures”. Such patient safety measures are consistent with recommendations by the President’s Advisory Commission on Consumer Protection and Quality in the Health Care Industry and are designed to help reduce medical and medication errors. Other criteria are directed at improved patient outcomes, higher nursing staff ratios, and electronic submissions. This is a new incentive program that is expected to evolve over time. Skilled Nursing Facilities, Rehabilitation Hospitals, and other care facilities: Most Skilled Nursing Facilities and other special care facilities are paid per diem rates, which are specific amounts paid for each day a Covered Person is in the facility. These amounts may vary according to the intensity of the Covered Services provided. Ambulatory Surgical Facilities (ASFs): Most ASFs are paid specific rates based on the type of Covered Service performed. For a few services, some ASFs are paid based on a percentage of billed charges.
INSTITUTIONAL PROVIDERS
