The document provides an overview of the complex U.S. healthcare system, including its decentralized market-based structure compared to other countries' centralized systems. It discusses key players like doctors, hospitals, insurers, and governments. It also covers major public programs like Medicare and Medicaid, as well as private insurance concepts like health plans, coding, and reimbursement structures including capitation and fee-for-service.

4. The Basic Mechanics The encounter The order(s) The bill The payment

5. Health Insurance: Risk v. Reward

26. CODING What I did and why I did it Each year, in the United States, health care insurers process over 5 billion claims for payment. Centers for Medicare and Medicaid Services, 2006

32. Service/Goods/Facilities America's Health Insurance Plans, a trade group for the managed care industry, said that a survey of its members found that 75 percent of current claims were now electronic, compared with 44 percent four years ago. New York Times, May 26, 2006

33. Service/Goods/Facilities UB04 Facility type claims Cover a period. Revenue Codes Developed by the American Hospital Association, to bill services, drugs, and supplies furnished in the hospital. These lines shows the total for ALL the charges for that type of service in that period. Prospective Payment Systems DRG In-Patient: Diagnosis Related Group APC Outpatient: Ambulatory Payment Classification Per-Diems

34. Service/Goods/Facilities RBRVS Resource Based Relative Value Scale President George H.W. Bush Omnibus Budget Reconciliation Act, 1989 1988- Dr. William Hsaio Harvard University Relative Values Assigned - Physician Work - Practice Expense Facility Non-Facility - Malpractice Geographically adjusted - GPCI (“gypsy”) CMS 1500 (08/05)

35. Relative Value Update Committee Determines the Resource Based Relative Value for each new code and revalues all existing codes at least once every five years. The RUC has 29 members, 23 of whom are appointed by major national medical societies. The six remaining seats are held by the Chair (an AMA appointee), an AMA representative, a representative from the CPT Editorial Panel, a representative from the American Osteopathic Association, a representative from the Health Care Professions Advisory Committee and a representative from the Practice Expense Review Committee. Who Decides?

36. How do I use it? Find the CPT code It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/

37. How do I use it? Determine the GPCI (Geographic Practice Cost Index) for each RVU It’s on the CMS web site: http://www.cms.hhs.gov/PhysicianFeeSched/

38. How do I use it? Multiply the RVUs by their GPCIs Multiple the WORK result by the Budget Neutrality Factor

39. How do I use it? Add the adjusted RVU totals

40. How do I use it? Multiply the adjusted RVU total by the National Conversion Factor and you’re done!

41. or, you can go to: http://www.medicarenhic.com/cal_prov/fee_sched.shtml And download the fee schedule!