What reimbursement models are commonly used in post-acute care, and how can practitioners optimize reimbursement and payment processing in these settings?
In post-acute care, several reimbursement models are commonly used, each with requirements and guidelines. The two primary reimbursement models are:
- Medicare Fee-for-Service (FFS): Under this model, healthcare providers are reimbursed based on the fee schedule established by the Centers for Medicare and Medicaid Services (CMS). This model pays providers for each service rendered, and reimbursement rates are typically determined by the diagnosis-related group (DRG) or the Resource Utilization Group (RUG) system, which categorizes patients based on their clinical characteristics and care needs.
- Medicare Advantage (MA): MA plans, or Medicare Part C, are offered by private insurance companies approved by Medicare. These plans provide an alternative to traditional Medicare and often use a managed care approach, such as health maintenance organizations (HMOs) or preferred provider organizations (PPOs). The reimbursement structure for MA plans may vary depending on the specific contract between the provider and the insurance company. Practitioners can optimize reimbursement in MA plans by understanding the plan’s specific requirements, ensuring timely and accurate documentation, and maintaining effective communication with the insurance company.
While these two models can result in easier, more efficient reimbursement, they can only stretch so far. Practitioners can consider ulterior strategies to optimize reimbursement and payment processing in post-acute care settings. Here’s Saisystems’ President of Customer Success, David Lane, on how post-acute long-term care practices can optimize these reimbursement models.
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