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A prospective payment system (PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided. It includes a system for paying hospitals based on predetermined prices, from Medicare.
Utilization management is "a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision-making through case-by-case assessments of the appropriateness of care prior to its provision," as defined by the Institute of Medicine [1] Committee on Utilization Management by Third Parties (1989; IOM is now the National ...
By 2001, "case rates for episodes of illness" (bundled payments) were recognized as one type of "blended payment method" (combining retrospective and prospective payment) along with "capitation with fee-for-service carve-outs" and "specialty budgets with fee-for-service or 'contact' capitation."
The two methods yield identical results (assuming bases are the same for both prospective and retrospective calculations). As an example, consider a whole life insurance policy of one dollar issued on (x) with yearly premiums paid at the start of the year and death benefit paid at the end of the year.
Retrospectively rated insurance is a type of insurance that uses retrospective rating: a method of establishing a premium on large commercial accounts. The final premium is based on the insured's actual loss experience during the policy term, sometimes subject to a minimum and maximum premium, with the final premium determined by a formula.
The prospective payment system implemented as DRGs had been designed to limit the share of hospital revenues derived from the Medicare program budget. [11] In 1982 the US Congress passed Tax Equity and Fiscal Responsibility Act with provisions to reform Medicare payment, and in 1983, an amendment was passed to use DRGs for Medicare, [ 7 ] : 16 ...
"Additional premium provision" means, in the context of finite risk insurance, a provision of an insurance or reinsurance contract that requires or strongly encourages the insured to pay the insurer some calculable amount as a result of losses paid or incurred under that insurance or reinsurance contract, excluding provisions for additional premium due to changes in exposure or policy audit.
Financial reinsurance in various forms (finite, surplus relief, funded, etc.) consists of various approaches to reinsurance involving a very high level of prospective or retrospective premiums relative to the quantity of risk assumed. While such approaches involve "risk finance" as opposed to "risk transfer," they are still generally referred ...