Chapter 9: CMS Reimbursement Methodologies

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Questions and Answers

What are All Patient Diagnosis-Related Groups (AP-DRGs)?

A Medicare-specific payment system

A system for outpatient care reimbursement

A DRG system for non-Medicare beneficiaries (correct)

A method for billing patients directly

What do All Patient Refined Diagnosis-Related Groups (APR-DRGs) classify patients based on?

Only age and gender

Types of treatment received

Reason for admission, severity of illness, and risk of mortality (correct)

Region of treatment

What is an ambulance fee schedule?

A payment system for ambulance services provided to Medicare beneficiaries

What are ambulatory payment classifications (APCs)?

A prospective payment system for outpatient care reimbursement Signup and view all the answers

Define ambulatory surgical center (ASC).

A state-licensed, Medicare-certified supplier of surgical health care services Signup and view all the answers

The ambulatory surgical center payment system uses the outpatient prospective payment system's relative payment weights as a guide for reimbursing __________.

ambulatory surgery centers Signup and view all the answers

Is balance billing allowed under Medicare?

False Signup and view all the answers

What is bundled payment?

A predetermined payment amount for all services provided during an episode of care Signup and view all the answers

What does the case mix refer to?

Types and categories of patients treated Signup and view all the answers

What is a clinical laboratory fee schedule?

A data set based on local fee schedules Signup and view all the answers

What is the CMS Quarterly Provider Update (QPU)?

An online CMS publication with regulatory and policy information Signup and view all the answers

Describe the conversion factor in Medicare.

A dollar multiplier that converts relative value units into payment Signup and view all the answers

What is the purpose of the end-stage renal disease prospective payment system (ESRD PPS)?

To provide a single per-treatment payment covering all resources used in outpatient dialysis Signup and view all the answers

What does a durable medical equipment prosthetics/orthotics, and supplies (DMEPOS) fee schedule cover?

Medicare reimbursement for DMEPOS based on actual charges or fee schedule amounts Signup and view all the answers

What is a disproportionate share hospital (DSH) adjustment?

Increased payments for hospitals treating a high percentage of low-income patients Signup and view all the answers

What is meant by 'episode of care' in home health?

A period of time (two months) during which home health care is provided Signup and view all the answers

Define a federally qualified health center (FQHC).

A safety net provider that offers services typically furnished in an outpatient clinic Signup and view all the answers

What is the federally qualified health centers prospective payment system (FQHC PPS)?

A national encounter-based rate with geographic and other adjustments Signup and view all the answers

Study Notes

Reimbursement Methodologies Overview

All Patient Diagnosis-Related Groups (AP-DRGs) are used by third-party payers for hospital reimbursement based on resource intensity for non-Medicare patients.
All Patient Refined Diagnosis-Related Groups (APR-DRGs) classify patients based on admission reason, severity of illness (SOI), and risk of mortality (ROM).

Service Payment Models

Ambulance Fee Schedule outlines how Medicare reimburses ambulance services for beneficiaries.
Ambulatory Payment Classifications (APCs) are a prospective payment system for outpatient care, calculating reimbursement based on similar services.
Ambulatory Surgical Centers (ASC) are state-licensed entities providing surgical services, certified to accept Medicare claims.
Payment for ASCs is determined by the outpatient prospective payment system's relative payment weights.

Reporting and Compliance

The Ambulatory Surgical Center Quality Reporting (ASCQR) program encourages ASCs to meet administrative and reporting requirements to avoid payment reductions.
Balance billing involves charging beneficiaries for unpaid amounts by payers, except copayments, which is prohibited under Medicare regulations.

Payment Structures

Bundled payments represent a predetermined amount for all services during an episode of care.
Case mix refers to the diverse categories of patients treated by a healthcare facility or provider, impacting financial and care strategies.
The Case-Mix Index assigns relative weights for a facility's patient population to help calculate reimbursement.
Case-Mix Management uses data analytics to predict healthcare needs based on patient categories treated.

Payment Determination

Case rate payment is fixed for an encounter, irrespective of services or duration.
Clinical Laboratory Fee Schedule is structured based on local fee tables.
The CMS Quarterly Provider Update (QPU) is an online resource detailing important regulations and policy changes.

Financial Calculations

Conversion factor is a dollar multiplier in the Medicare physician fee schedule (MPFS) used to convert relative value units (RVUs) into payment.
Diagnosis-Related Groups (DRGs) are a prospective payment model that reimburses hospitals for inpatient stays.

Specialty Adjustments and Provisions

Disproportionate Share Hospital (DSH) Adjustment rewards hospitals treating low-income patients with higher Medicare payments.
Durable Medical Equipment, Prosthetics/Orthotics, and Supplies (DMEPOS) Fee Schedule indicates Medicare reimbursement is capped at 80% of the actual charge or set fee amount.
End-Stage Renal Disease Prospective Payment System (ESRD PPS) pays a per-treatment rate to facilities for outpatient dialysis.

Healthcare Accessibility

Episode of Care in home health refers to a two-month period of care for a specific condition.
Federally Qualified Health Centers (FQHC) serve as safety-net providers mainly delivering outpatient clinic services.
The FQHC Prospective Payment System (FQHC PPS) offers a national encounter-based rate, adjusted by geographic and other factors, established by the Affordable Care Act.

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Explore key concepts from Chapter 9 on CMS Reimbursement Methodologies with these flashcards. Learn about different patient diagnosis-related groups and their significance in healthcare reimbursement systems. This quiz is designed to reinforce your understanding of these critical topics.