Compensation and Reimbursement Plans

One way in which a MCO can control cost, quality, and access is through various structured compensation and reimbursement plans. The two most common examples are fee for service and capitation. Moreover, there are different types of reimbursement systems for inpatient and outpatient services. Answer the following questions in regard to the above information:

• Examine the three types of inpatient or outpatient reimbursement systems?
• Evaluate the key advantages and disadvantages of each system from the point of view of a managed care plan and the hospital?
• What is the difference between capitation and FFS? Evaluate the type of market appropriate for each reimbursement method. Support your answer by providing an example of an MCO using either of these methods.
• What do you understand by the term "UCR"? With what form of reimbursement is this term associated? Search current information from the Internet and evaluate the use of UCR in the managed care industry.

Reimbursement procedures are complex and detailed, especially those associated with government programs such as Medicare. Part of the regulatory requirements of Medicare is to prevent illegal billing practices such as churning, upcoding, and unbundling. You can search these topics by clicking here. You can also search on federal regulations for reimbursement procedures and fraud and compliance guidelines and education materials.

Based on your research, respond to the following questions:

• Review the latest enforcement actions on this website. Identify a case where at least one of the following illegal actions was used