Reimbursement Methods & Fee Schedules Flashcards
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What is a Diagnosis-Related Group (DRG) payment system used for?
Answer: A prospective payment system for inpatient hospital stays based on diagnosis
DRGs are used in the Medicare Inpatient Prospective Payment System, where hospitals receive a fixed payment based on the patient's principal diagnosis and procedures.
What is the Ambulatory Payment Classification (APC) system used for?
Answer: Reimbursing hospital outpatient department services under Medicare
APCs are the basis of Medicare's Outpatient Prospective Payment System (OPPS), grouping outpatient services into categories with predetermined payment rates.
What does a 'global surgical package' include?
Answer: Pre-operative, intraoperative, and post-operative care within a defined period for a single payment
The global surgical package bundles pre-op visits, the surgery itself, and post-op care into a single reimbursement amount, with the global period varying by procedure.
What is a contractual adjustment in medical billing?
Answer: The difference between a provider's billed charge and the contracted allowed amount that is written off
A contractual adjustment is the amount a participating provider writes off because their billed charge exceeds the payer's contracted allowed amount.
What is the Resource-Based Relative Value Scale (RBRVS)?
Answer: A system that values physician services based on resources required, including work, practice expense, and malpractice
The RBRVS was developed to standardize Medicare physician payments based on the actual resources required to provide each service.
What does 'value-based reimbursement' emphasize compared to fee-for-service?
Answer: Quality of care and patient outcomes rather than quantity of services
Value-based reimbursement models tie provider payments to the quality and efficiency of care delivered, rather than simply the quantity of services.