Healthcare reimbursement systems can be complex and difficult to understand. Each payor may use a different method to reimburse providers, or they may use a variation of a commonly used method. This course will provide a foundation for understanding the common reimbursement systems in use today.
We start with Medicare's reimbursement systems of RBRVS, DRGs, and APCs because many other payors use modified versions of these systems. We then discuss other payor types such as HMOs, PPOs, and ACOs and how these organizations use other reimbursement methods such as capitation, per diems, and carve outs. Finally, we discuss the key data elements needed to adjudicate claims according to each scheme, and we discuss the financial incentives (and disincentives) associated with each method.