Understanding the CMS Prospective Payment System- Schedules, Examples, and Case Mix Adjustments

Understanding the CMS Prospective Payment System- Schedules, Examples, and Case Mix Adjustments

The Schedules of CMS

The federal government offers various healthcare programs (Green & Rowell 2018), including Medicare, which uses a Prospective Payment System consisting of schedules divided into ambulatory, long-term care, access to a physician, nursing, resource-based, and laboratory fees. Ambulatory fees include Ambulance Surgical Center Payment and Ambulance Fee Schedule. Long-term care fees include Long-Term Care Hospital fees. Access to a physician includes Home Health, Hospital Outpatient, Hospital Inpatient, Inpatient Rehabilitation Facility, Inpatient Psychiatric Facility, and End-Stage Renal Disease (ESRD) Composite fees. Nursing comprises a Skilled Nursing Facility Prospective fees. Further, resource-based fees include Resource-Based Relative Value Scale and Durable Medical Equipment, Prosthetics/Orthotics, and Supplies fees. Laboratory fees include the Clinical Laboratory Fee Schedule. Hire our assignment writing services in case your assignment is devastating you.

Example of a Charge for Each Schedule

 The Case-Mix Concept That Alters Payment Rates

The case-mix concept is a patient classification to improve clinical and financial management in healthcare facilities (Costa et al., 2015). It portrays the diversity of the patient population, resource requirements, and clinical services complexity. It enables healthcare providers to predict future healthcare needs by analyzing data analytics on the categories of patients treated. It also helps stakeholders understand a billing system used in a healthcare facility and measures the performance of the healthcare facility to reward initiatives that increase efficiency in a healthcare facility.

The Diagnosis-Related Group Payment System

The diagnosis-related group payment system is the classification framework used in the case-mix funding structure (Zhao et al., 2018). It mainly classifies episodes of acute inpatients into various manageable classes based on the consumption of resources and clinical conditions. Medicare uses the groups to set payments based on the patient category in a healthcare facility rather than paying for every service.

References

Costa, A. P., Poss, J. W., & McKillop, I. (2015). Contemplating case mix. Healthcare Management Forum, 28(1), 12-15. https://doi.org/10.1177/0840470414551866

Green, M., & Rowell, J. (2018). Understanding health insurance: A guide to billing and reimbursement. Cengage Learning.

Zhao, C., Wang, C., Shen, C., & Wang, Q. (2018). Diagnosis-related group (DRG)-based case-mix funding system, a promising alternative for fee for service payment in China. BioScience Trends, 12(2), 109-115. https://doi.org/10.5582/

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Introduction:

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

Understanding the CMS Prospective Payment System- Schedules, Examples, and Case Mix Adjustments

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.
Submission Details:

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