CMS Reimbursement and Essential

CMS Reimbursement and Essential

CMS has a variety of fee schedules. The schedules guide Medicare on fees to pay suppliers, providers, or doctors (Axene Health Partners, LLC., 2021). CMS’s fee schedules address ambulance services, physicians, prosthetics, supplies, orthotics, durable medical equipment, and clinical laboratory services (CMS.gov, 2021).

Various aspects determine the payment rates. These include the age of the patient, reported comorbidities, and documentation. For instance, if Medicare is supposed to reimburse $128 for a particular service, the ages of patients would play a key role in determining the payment. A patient aged between 60 and 69 years may only cost Medicare the recommended $128. A 58-year-old individual may cost Medicare more because the recommended amount is multiplied by the case-mix index multiplier. The older patients tend to need more care than younger individuals. This aspect increases the reimbursements that Medicare makes when older patients seek care.

The diagnosis-related group (DRG) enlists different discharges based on complications, comorbidities, and all primary or secondary procedures performed. This payment system determines the amount that Medicare reimburses the facility. The main determining factor is the average amount of resources used to treat patients within a specific DRG. Different elements, such as outliers, indirect medical education (IDE) adjustment, and disproportionate share hospital (DSH) adjustment, can lead to changes in the reimbursement amount. In case a patient is transferred to a post-acute facility, the IPPS transfer rule treats this as a transfer. Thus, the hospital receives a graduated per diem payment to cover the patient’s daily stay. This ensures the DRG rates are not exceeded (Green & Rowell, 2011).

References

Axene Health Partners, LLC. (2021). Physician Fee Schedules: How Do They Compare and What’s Next? Retrieved from https://axenehp.com/physician-fee-schedules-compare-whats-next/

CMS.gov. (2021). Clinical Laboratory Fee Schedule. Retrieved from Centers for Medicare & Medicaid Services: https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/ClinicalLabFeeSched

Green, M. A., & Rowell, J. C. (2011). Understanding Health Insurance, A Guide to Billing and Reimbursement. Cengage Learning.

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The Prospective Payment System of CMS consists of thirteen schedules that allow the calculation of payment for a patient encounter. The DRG or price-based system covers inpatient charges from one of these schedules.

CMS Reimbursement and Essential

Tasks:
Describe the schedules of CMS.
Provide an example of a charge for each schedule.
Describe the case mix concept that alters payment rates.
Describe the diagnosis-related group payment system.
To support your work, use your course and textbook readings and also use the South University Online Library. As in all assignments, cite your sources in your work and provide references for the citations in APA format.

Your initial posting should be addressed in 150–300 words. Submit your document to this Discussion Area by the due date assigned.