week 3 discussion
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School
South University, Austin *
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Course
2005
Subject
Medicine
Date
Feb 20, 2024
Type
docx
Pages
4
Uploaded by AmbassadorSnail2965
The fee schedule of the CMS is a listing of the maximum fees that the agency can reimburse providers for various services. Some of these include ambulance services, clinical laboratory services, durable medical equipment, and physicians. In 1997, the Balanced Budget Act provided for the establishment of a fee schedule for ambulance services that were provided to Medicare recipients. For
instance, an ambulance company charged Medicare $600 for transporting a patient to the hospital, and the government paid 80% of that amount. Medicare is responsible for paying the $425 fee to the ambulance service. This is equivalent to the fee schedule's predetermined rate. The fee schedule for clinical laboratories is a
collection of information based on the local fee schedules for services such as outpatient diagnostic tests. Medicare covers the lowest applicable fee schedule amount for these services. Below is an example of Clinical Laboratory Fee Schedule:
Medicare will reimburse you for the difference between the actual cost and the fee schedule amount for durable medical equipment, orthotics, and prosthetic supplies.
Example:
The Medicare physician fee schedule reimburses providers based on the rates CMS
establishes for certain services. All the services are standardized and can be compared to determine the value of each service. Example:
A higher case mix index means that hospitals can provide more effective and efficient care to their patients. It also helps them earn more money from their operations. One of the most important factors that a hospital must consider when it comes to improving its case mix is having the necessary clinical records. Medicare and private insurance companies pay a set amount based on the diagnosis-related group payment system to determine how much they will pay for a patient's hospital stay. This method differs from the way hospitals are paid for certain services.
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References:
Davis, E. (2020, November 26). Learn about diagnostic related grouping and how it works. Verywell Health. Retrieved June 16, 2022, from https://www.verywellhealth.com/drg101-what-is-a-drg-how-does-it-work-
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Green, M. (2020). Understanding Health Insurance: A Guide to Billing and Reimbursement - 2020 (15th Edition). Cengage Limited. https://digitalbookshelf.southuniversity.edu/books/9780357769157
Letoureau, R. (2015, February 16). CDI Programs drive UP case mix index, revenue. HealthLeaders Media. Retrieved June 16, 2022, from https://www.healthleadersmedia.com/finance/cdi-programs-drive-case-mix-
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