THIS IS A QUESTION FROM PENN FOSTERS FINAL EXAM 40976200 NUMBER 4 ON PART B.
YOU'RE AN INPATIENT CODER IN A HOSPITAL. YOU'VE JUST CODED A MEDICARE PART A RECORD WITH A DIAGNOSTIC-RELATED GROUP (DRG) REIMBURSEMENT OF $12000. YOU NOTICE IN THE HOSPITAL'S COMPUTER BILLING SYSTEM THAT THE PATIENT'S CHARGES ARE $19,500. THAT'S $7,500 MORE THAN THE HOSPITAL WILL BE REIMBURSED. HOW DOES THE DIFFERENCE BETWEEN THE CHARGES GET RESOLVED?
First --
When you type in all-caps, two things happen:
**it's harder to read, and
**it's the online equivalent to SHOUTING (considered rude behavior).
Please just type in regular mode, not with the Caps Lock feature turned on. Thanks.
Second --
What is your specific question?
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To resolve the difference between the charges and the reimbursement in this scenario, several factors need to be considered.
First, it is important to understand that the reimbursement for Medicare Part A records is based on a Diagnostic-Related Group (DRG) system. DRGs are used to categorize patients with similar diagnoses and procedures and assign them a fixed payment amount. Therefore, the reimbursement amount of $12,000 is predetermined based on the specific DRG assigned to the patient.
The charges, on the other hand, represent the actual cost of services provided by the hospital. These charges are typically higher than the reimbursement amount, reflecting the various costs involved in delivering healthcare such as staffing, equipment, overhead expenses, etc.
When there is a difference between the charges and the reimbursement, the hospital needs to address this discrepancy. There are a few ways this can be resolved:
1. Contractual Agreements: Hospitals often have contracts with insurance companies, including Medicare, that specify the terms of reimbursement. These contracts may include negotiated rates or percentage reductions on charges. Therefore, the hospital may agree to accept the reimbursement amount as full payment according to the terms of the contract.
2. Write-Offs or Adjustments: In some cases, the hospital may choose to write-off or adjust the difference between the charges and the reimbursement. This means that the hospital agrees to absorb the additional cost and does not bill the patient or insurance company for the remaining amount.
3. Appeal Process: If the hospital believes that the reimbursement is inadequate based on the care provided or other factors, they may choose to appeal the decision. This involves submitting additional documentation and evidence to justify a higher reimbursement amount.
Ultimately, the specific approach to resolving the difference between charges and reimbursement may vary depending on the hospital's contractual agreements, financial policies, and applicable regulations. It is important for the hospital to monitor reimbursement rates and manage their finances properly to ensure they can continue to provide quality care.