Reimbursement Methods & Fee Schedules Flashcards
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What is a fee-for-service (FFS) reimbursement model?
Answer: Paying providers for each individual service or procedure performed
In fee-for-service, providers are paid a separate fee for each service rendered, incentivizing volume of services rather than outcomes.
What is capitation in managed care reimbursement?
Answer: A fixed per-member-per-month payment to a provider for all covered services regardless of utilization
Capitation pays providers a set monthly amount for each enrolled patient, regardless of whether that patient seeks services.
What is the Medicare Physician Fee Schedule (MPFS)?
Answer: A payment schedule that determines how much Medicare pays physicians for covered services based on RVUs
The MPFS establishes payment rates for services provided by physicians and other qualified professionals under Medicare Part B, calculated using relative value units.
What does a relative value unit (RVU) represent in physician reimbursement?
Answer: A numeric value representing the work, practice expense, and malpractice components of a medical service
RVUs quantify the physician work, practice expenses, and malpractice insurance costs associated with each service, forming the basis of Medicare physician payments.
In the Medicare Physician Fee Schedule, what is the 'conversion factor'?
Answer: A dollar amount multiplied by total RVUs to calculate Medicare's payment for a service
The conversion factor is a national dollar amount set by CMS annually that, when multiplied by the total RVUs for a service, determines the Medicare payment rate.
What is a bundled payment model?
Answer: A single payment to cover all services related to a specific episode of care or condition
Bundled payments provide a single lump-sum payment for all services during a defined episode of care, encouraging coordination and efficiency.