Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Health Systems
Course Outcomes
Introduction to hospital billing and Facility E/M guidelines Payment Methodologies
MS-DRGs APCs
Addendum B OCE Edits
RBRVS
Fee for service
Reimbursement Methodologies
Reimbursement Methodologies
An Inpatient Prospective Payment System (IPPS) was implemented in 1983 Generally, payment was based on grouping Major Diagnostic Categories (MDCs) into Diagnosis Related Groups (DRGs) As a result, hospitals started shifting services to the outpatient setting where reimbursement was still based on cost.
OPPS
Medicares response to the increased spending on outpatient healthcare services Authorized by the Balanced Budget Act of 1997 to develop an OPPS culminating in the implementation of APCs in August 2000
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Payment Components
MS-DRGs ICD-9 Codes APCs HCPCS Codes RBRVS HCPCS codes
MDC
MS-DRG Group Complications/ CoMorbidities
APC Group
Status Indicator Payment Rate
Physician work
Practice Expense Malpractice Insurance
Relative Rate
Average LOS
Relative weight
Coinsurance
MS-DRG Classification
The MS-DRGs (Medicare Severity DRGs) are a patient classification system which provides a means of relating types of patients a hospital treats (i.e., its case mix) to the costs incurred by the hospital. Payment for inpatient hospital services is made on the basis of a rate per discharge that varies according to the MS-DRG to which a beneficiary's stay is assigned. All inpatient transfer/discharge bills from both PPS and non-PPS facilities, including those from waiver States, long-term care facilities, and excluded units are classified by the Grouper software program into one of 745 diagnosis related groups (DRGs).
OPPS applies to all hospital outpatient departments , except for some specified facility types (for example Critical Access hospitals)
In the Beginning
Before APCs
Outpatient reimbursement was based on charges Reimbursement was usually not affected if the hospital forgot to report a HCPCS code Levels of E/M didnt exist Coding was a HIM function
The OCE software performs the following functions when processing a claim:
Edits a claim for accuracy of submitted data Assigns APCs Assigns CMS-designated status indicators Assigns payment indicators Computes discounts, if applicable Determines a claim disposition based on generated edits Determines if packaging is applicable Determines payment adjustment, if applicable
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Disposition
Claim Rejection
Description
The provider can correct and resubmit the claim but cannot appeal the claim rejection. The provider can not resubmit the claim but can appeal the claim denial The provider can resubmit the claim one the problems are corrected
Claim Denial
Claim Suspension
The claim is not returned to the provider, but is not processed for payment until the FI/MAC makes a determination or obtains further information.
The claim can be processed for payment with some line items rejected for payment. The line item can be corrected and resubmitted but cannot be appealed. The claim can be processed for payment with some line items denied for payment. The line item cannot be resubmitted but can be appealed
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Possible Challenges
Possible Challenges
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Possible Challenges
Hospitals must regularly review and become familiar with National and Local Coverage Determinations.
Since outdated CDMs create a significant compliance risk, Hospitals must assure timely updates, proper use of modifiers, and correct associations between revenue and procedure codes.
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Medicare RBRVS was developed through the 1980s and implementation began in 1992 as a 5-year phase-in from UCR (lower of usual, customary, or reasonable charges)
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Hospital Payment
$168.92 Payment Increase Discounted RBRVS $162.41 $331.33
RBRVS $197.06
Example: Reimbursement for New Patient Visit 99205 (Medicare National payment amounts)
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Managing both technical and profee revenue in a manner that optimizes revenue generation requires the following:
A broad knowledge base of the differences and similarities in payment methodologies for provider types An understanding of how the pieces of the puzzle fit together A global approach to the decision making process If you make a certain decision for profee billing what are your considerations and how will you impact the technical billing?
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Who is the go to resource in your organization for all things financial and revenue operations related for the Clinical Partners and the coding billing staff? We can help you formulate the plan that best suits your organization.
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