Institute:Office of National Coordinator (ONC) Workforce Training Curriculum
Component:Introduction to Health Care and Public Health in the U.S.
Unit:Financing Health Care - Part 2
Lecture:The Billing Process of Various Health Care Enterprises
Slide content:3rd Party reimbursement Reimbursement Methodology Fee-for-service ( FFS ): Separate payments made for each individual service provided Episode-of-care: Payment of one sum for providing all services or care during a illness or time frame Example: Patient with cough and fever is treated at urgent care 9
Slide notes:The payment a provider receives from a third party payor depends on the methodology applied to a specific claim. After submission to the payor, a medical claims examiner or adjuster processes it according to the insurance plans guidelines and the terms of the policy. Third party payors use different methodologies to determine the amount to pay for a specific claim. Payments for claims are based on one of two methodologies: fee-for-service or episode-of-care, both of which describe a unit of payment. Fee-for-service refers to separate payments made for each individual service provided, whereas episode-of-care refers to one payment for all care provided during an illness or time frame. For example, a patient with a cough and fever is examined and treated at an urgent care center. The center provides three services for this patient: the doctors professional fees, an x-ray, and a blood test. With fee-for-service reimbursement, the provider receives payment for each of the three services individually. With episode-of-care payment, the center receives one payment for all three services the same pre-determined amount whether one, two, or all three of the services are performed. This single fee for all services is negotiated by the provider with the payor in advance as part of managed care arrangements. Health IT Workforce Curriculum Version 4.0 9