Ngokusho kwe-CMS, izimangalo ezingaphezu kwezigidi eziyi-5 zezokwelapha zithunyelwa ukukhokhelwa unyaka ngamunye. Ukwenza ikhodi eqinisekisiwe kubalulekile ukuqinisekisa ukuthi lezi zimangalo zicutshungulwa ngendlela ehambisanayo. Izinkampani zomshuwalense, abakhokhisi bezinkampani zangaphandle, kanye nemithethonqubo yesifundazwe kanye nesifundazwe baye babonisa ukukhathazeka okwandayo ngokubaluleka kokubhaliswa okunembile kwezinsizakalo zeziguli.
Lapho abahlinzeki behluleka ukuhambisana nezidingo zokukhokhwa ezidingekayo ekusetshenzisweni kwezinkampani zokukhokha, ithuba lokukhokha okungalungile landa.
I-Medicare isebenzisa uhlelo lwe-PPS (uhlelo lokukhokhela okulindelekile) kanye namashejuli wemali esebenzisa indlela yokubuyisela esekelwe esilinganisweni esilinganiselwe. Kunezinhlelo ze-PPS kanye namashejuli wemali esekelwe kumasevisi anikeziwe.
Izinhlelo Zokukhokha Ezithintekayo
- Izibhedlela ezigula kakhulu
- I-ejensi yezempilo yasekhaya
- Izibhedlela
- Isiguli esibhedlela
- Izakhiwo ezingelapheki zengqondo
- Izakhiwo zokuvuselela iziguli
- Izibhedlela zokunakekelwa isikhathi eside
- Izakhiwo zokwelapha abanekhono
Amashejuli Emaholo
- Odokotela
- Ambulance services
- Izinsizakalo ze-laboratory zemitholampilo
- Imishini yezokwelapha ehlala njalo, izidakamizwa, izidakamizwa, nempahla
Ngaphansi kokuhlelwa kwe-PPS kanye ne-Fee Schedule, umhlinzeki ngamunye uyabuyiselwa imali esinqunyiwe esekelwe ikhodi yenqubo ebikiwe. Ukukhokhwa okungalungile kungaholela ekuhlulekeni ukuhambisana nezidingo zokufaka ikhodi.
Kunezindawo eziyishumi ezihlotshaniswa nenqubo engafanele yokuphulukisa iziguli.
- Ukubika amayunithi enkonzo angalungile
- Ukukhokhiswa okungalungile kwezinsiza zokubona
- Ukubika amacala angalungile ngenxa yezincazelo zekhajaji ezedlule
- Ukuhambisa izinkokhelo eziphindwe kabili noma ukuhluleka ukulandela imihlahlandlela ye-NCCI (National Correct Coding Initiative) ye-Medicare ne-Medicaid
- Ukubika okungalungile kwekhodi yenqubo yokuguqula
- Ukukhetha ikhodi engalungile ye- E / M (Ukuhlola nokuphathwa)
- Ukubika inqubo "yokwelapha kuphela" kwisimangalo sesipiliyoni
- Ukuhambisa izicelo zokwelashwa okungadingekile
- Ukuhluleka ukulandela imithetho eminingi yokukhipha izinqubo
- Izinsizakalo ezinikezwa ngumfundi, ohlala kuzo noma omunye ochwepheshe abanezinga elingavunyelwe ngaphandle komqondisi odokotela
Amaphutha okuqamba ikhodi angabalwa ngezici eziningana.
- Izingcindezi zesikhathi kanye / noma ukuvimbela
- Iziphazamiso
- Ukungabi nalutho lokuthola ikhodi
- Iphutha lomuntu
- Ukungabi nokuxhumana
- Amafomu okuhlangana ngesiguli esiphelelwe yisikhathi
Lezi zici zivame ukungazenzisi kodwa uma amaphutha okubhala ikholakala ngesisekelo esifanayo, abahlinzeki bangase babhekwe njengokwephulwa koMthetho Wamanga Wama-Claim for imikhuba yokukhokha ehlukumezayo. Ukukhwabanisa ngezinye izikhathi kudidekile nokuhlukunyezwa. Ukuhlukumeza ukukhokhiswa okungenhloso ngokweqile kwezinto noma amasevisi angakahlinzekiwe. Izindawo ezine ezivamile ezikhonjelwa ngokuthi Ukukhwabanisa noma Ukuhlukunyezwa yizi:
- Ukukhokhwa Kwezinsiza Zezokwelapha Akuzange Kuhlinzekwe
Indawo ejwayelekile kakhulu yokukhwabanisa kwe-Medicare yikhokhwa yezinsiza zokwelashwa ezihlala njalo (DME). I-DME ibhekisela kunoma imiphi imishini yokwelapha edingekayo esimweni sezokwelapha noma ngokomzimba wesiguli. Ihlanganisa izihlalo zabakhubazekile, imibhede yezibhedlela, nezinye izinto zokusebenza zalowo mvelo. Umhlinzeki uzokhipha imali kuMedare for imishini isiguli esingakaze sithole. Izikolo zokuhamba ziye zithandwa ikakhulukazi kuma-scheme wokukhwabanisa ama-Medicare.
- Ukukhokhwa Kwezinsizakalo akukaze kwenziwe
Kulesi sibonelo, izikhwama zomhlinzeki zokuhlolwa, ukwelashwa noma izinqubo azange zenziwe. Lokhu kungafakwa ohlwini lokuhlolwa isiguli esitholile futhi asiqapheli. Umhlinzeki angaphinde akhohlise amakhodi wokuxilongwa ukuze afake izivivinyo ezingadingekile noma izinsizakalo ezingadingekile.
- Izinkokhelo zokuhlaziya
Ukungahlehlisi izinga lensizakalo noma inqubo eyenziwe ukuze ukhokhise ngaphezulu noma uthole izinga eliphezulu lokubuyiselwa kubhekwe ukukhishwa kwekhodi. Ukukhishwa kwe-upcoding kwenzeka nangabe isevisi eyenziwe ayihlanganiswa yi-Medicare kodwa izikweletu zomhlinzeki zihlinzeke ngenkonzo ehlanganisiwe endaweni yayo.
- Ukukhishwa kwamacala
Ezinye izinsizakalo zibhekwa njengezozonke. Ukukhipha ukukhokhisa ukukhokhisa ngezinqubo ezihlukene ngokweqile ezikhokhiswa njengekhokhwa elilodwa. Isibonelo, izikhwama zomhlinzeki zezimpawu ezimbili zokuhlola okungahambisani nendawo, esikhundleni sokukhokhisa ukuhlolisisa okuphakathi kokubili kwezwe.
Ukukhokhwa kwe-coding ngokunembile kwenza umkhokheli womshuwalense azi izimpawu, ukugula noma ukulimala kwesiguli kanye nendlela yokwelapha eyenziwa udokotela. Amaphutha ekhodi yokukhokha ayenzeka uma isimangalo sithunyelwa kwinkampani yomshuwalense ngesifo sokuxilongwa okungalungile noma ikhodi yenqubo esimangalo. Ukukhokhwa okungalungile kungaholela emiphumeleni eminingi emibi. Kuyadingeka ukuthi ihhovisi lezokwelapha lihlakulele isimiso sokuhambisana nokuvimbela ukwephulwa kwezidingo zekhodi yezokwelapha.