A Primer on Acute Care Reimbursement: From DRGs to Bundled Payments
Instructor:
Toni Cesta
Product ID: 705824
Training Level: Basic to Intermediate
- Duration: 60 Min
Why Should You Attend:
The area of healthcare reimbursement has changed significantly since the introduction of the Prospective Payment System and its diagnosis related groups (DRGs) around 1985. DRGs were a reimbursement scheme aimed at controlling cost and length of stay. Because cost continued to rise, managed care organizations offered healthcare benefits at lower cost and began to proliferate. Most recently, the Centers for Medicare and Medicaid Services (CMS) has begun experimenting with bundled payments, a take-off on the earlier capitation methods.
Today, acute care settings must work with each of these reimbursement methods, creating some confusion as well as challenges for all concerned.
This program will provide a foundation of knowledge and understanding of the DRG system used as the structure for reimbursement under the Medicare and Medicaid programs. We will review the DRG relative weights, case mix index and expected lengths of stay. You will learn how to do Medical record coding in the context of how hospitals get reimbursed. How to do managed care and managed care contracting as well as the various managed care products currently on the market.
The program will conclude with a discussion on bundled payments and what case management professionals need to know in order to assist their organizations in controlling cost and length of stay in a bundled payment environment where patients may access care and use resources at any touch point on the continuum.
Areas Covered in the Webinar:
- Diagnosis related groups (DRG)
- Medicare
- Medicaid
- Managed care definition
- Managed care contracting
- Managed care products
- Bundled payments – Mandatory and voluntary
- Managing cost across the continuum
- What case managers need to know while educating patients
Who Will Benefit:
- Director of Case Management
- RN Case Managers
- Director of Finance
- Director of Social Work
- Social Workers
- Hospitalists
- Physician Advisors
- Directors of Nursing
Toni Cesta
Consultant and Owner, Case Management Concepts LLC
Toni G. Cesta, Ph.D., RN, FAAN is Partner and Health Care Consultant in Case Management Concepts, LLC, a consulting company which assists institutions in designing, implementing and evaluating acute care and community case management models, new documentation systems, and other strategies for improving care and reducing cost. The author of nine books, and a frequently sought after speaker, lecturer and consultant, Dr. Cesta is considered one of the primary thought leaders in the field of case management.
Dr. Cesta writes a monthly column called “Case Management Insider” in the Hospital Case Management journal in which she shares insights and information on current issues and trends in case management.
Prior to her current work as a case management consultant, Dr. Cesta was Senior Vice President – Operational Efficiency and Capacity Management at Lutheran Medical Center in Brooklyn, New York. She was responsible for case management, social work, discharge planning, utilization management, denial management, bed management, the patient navigator program, the clinical documentation improvement program and systems process improvement. Prior to her position as Senior Vice President at Lutheran Medical Center, Dr. Cesta has held positions as Corporate Vice President for Patient Flow Optimization at the North Shore – Long Island Jewish Health System and Director of Case Management, Saint Vincents Catholic Medical Centers of New York, in New York City and also designed and implemented a Master’s of Nursing in Case Management Program and Post-Master’s Certificate Program in Case Management at Pace University in Pleasantville, New York. Dr. Cesta completed seven years as a Commissioner for the Commission for Case Manager Certification.
Dr. Cesta has been active in the research and development of case management for over 25 years. Her research in case management has included two funded studies measuring the effects of a case management model on congestive heart failure and fractured hip patient populations, with measures of patient satisfaction, quality of life, and short and long term clinical perceptions and outcomes.
Dr. Cesta has presented topics on case management at national and international conferences and workshops. Her books include “Nursing Case Management: From Essentials to Advanced Practice Applications”, “The Case Manager’s Survival Guide: Winning Strategies in the New Healthcare Environment”, “The Case Manager’s Survival Guide: Winning Strategies for Clinical Practice”, “Survival Strategies for Nurses in Managed Care” and “Core Skills for Hospital Case Managers”. Dr. Cesta is Consulting Editor of “Hospital Case Management Journal” and “Discharge Planning Advisor”. In addition, she serves as editorial advisory board member of several case management journals and publications including “Strategies for Healthcare Excellence” and “The Journal of Care Management”.
Dr. Cesta has a BS in Biology from Wagner College, a BS in Nursing from Adelphi University, an MA in Nursing Administration from New York University, and a Ph.D. in Nursing Research and Theory Development from New York University.
Dr. Cesta is a Fellow of the American Academy of Nursing. Among her awards are included the “Nursing Service Administration Award” from the New York State Nurses Association, the Jessie M. Scott Award for excellence in research, practice and education from the American Nurses Association, and three “Book of the Year” awards from the American Journal of Nursing. In 2010, she was awarded the Brooklyn Leaders Award from the Arthritis Foundation.
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