MCCG212 - Week 7 Reimbursement Methodology Report - Ciara Santos
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School
Bryant and Stratton College, Buffalo *
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Course
212
Subject
Health Science
Date
Feb 20, 2024
Type
docx
Pages
3
Uploaded by ChancellorMongooseMaster840
Ciara Santos MCCG212
Week 7: Reimbursement Methodology Report February 18
th
, 2024
MCCG212 – Reimbursement Methodology Report Template
2
Reimbursem
ent System
Outpatient
Surgery
Center
Hospital
Inpatient
Laboratory
Services
Prescription
Drug Medicare
Hospital Outpatient Prospective Payment System
(OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get
for outpatient care provided to patients with Medicare. The rate of reimbursemen
t varies with the
location of the
hospital or clinic.
Inpatient Prospective Payment System
(IPPS). Under the IPPS, each
case is categorized into a diagnosis related group (DRG). Each DRG
has a payment weight assigned to it, based on
the average resources used to treat Medicare patients in that DRG.
Laboratory fee
schedule
A manufacturer'
s average sales price (ASP)
Medicare
Advantage
(Managed
Care) Part C
HMO or PPO
HMO or PPO
Laboratory fee
schedule
Medicare Part D only covers prescription drugs.
Medicaid
Fee-For-
Service (FFS) model. FFS rates are designed to pay doctors only for the care that Fee-For-
Service and Medicaid Managed Care
Laboratory fee
schedule
A manufacturer'
s average sales price (ASP)
MCCG212 – Reimbursement Methodology Report Template
3
Part 2: Medicare and Medicaid reimbursement systems follow similar processes. They both are categorized into a diagnosis-related group (DRG). A key difference is that you need to have Medicare part D to have your prescriptions covered. Whereas Medicaid is based on the manufacturer's average sales price (ASP). As a provider, I would choose the commercial insurance route. You can choose what companies you want to work with and set contracted rates to be reimbursed. Some of the challenges I would face would be treating patients who are
in-network, so the cost is lower for the patient. Out-of-network claims would be more expensive for the patients since they would have to pay the full price. This could cause patients to not want to be seen by you. Another challenge would be having the contracted rate not as high as you would like. You might charge $200 for an office visit but the contracted rate with the insurance company might only be $98.
Resources:
Clinical laboratory fee schedule. CMS. (n.d.).
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched
Physician fee schedule. CMS. (n.d.).
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/PhysicianFeeSched
Acute Inpatient PPS. CMS. (n.d.).
https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/AcuteInpatientPPS
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