1st Edition

Healthcare Payment Systems Fee Schedule Payment Systems

By Duane C. Abbey Copyright 2011

    For healthcare providers and patients alike, the ways of private third-party payer payment systems can be mysterious and oftentimes quite frustrating. Payment for hospital, nursing, or homecare services can be subject to a variety of payment systems including cost-based and charge-based or those with payments that are determined in advance. Knowing the specific rules needed to navigate each type of payment system is essential for all healthcare administrators and accountants.

    Healthcare Payment Systems: Fee Schedule Payment System, the second volume in a series by expert consultant and workshop facilitator Duane Abbey, is dedicated to fee schedule payment systems. Always accessible and entertaining in his approach, Dr. Abbey illustrates the diverse challenges involved with these systems through the discussion of reimbursement claims for several individuals in a fictitious community served by a hospital, a nursing facility, and a hospice among other healthcare providers, Including more than 60 very real scenarios that illustrate best practices for various fee payment challenges, this comprehensive volume —

    • Explores the general concept of usual, customary, and reasonable (UCR) that is often applied by private third-party payers
    • Provides web links to a number of essential resources including various government acts and manuals
    • Discusses in-depth what is arguably the most complex fee schedule system: the Medicare Physician Fee Schedule
    • Defines a comprehensive list of acronyms used in the medical payment industry

    Conceptually, fee schedule payment systems are one of the simpler approaches; however, even straightforward healthcare payment systems can, and indeed do, become quite complex. No payment system exists in a vacuum. In fact, when services are provided, the reimbursement from multiple payment systems may be required. This guide shows you how all these systems work, as well as how they interface with one another in everyday practical use. Understanding the differences among systems and learning how to navigate them can make a huge difference in whether a claim is accepted or not and how much payment is allowed.

     

    Introduction to Fee Schedule Payment Systems
    Overview of Healthcare Payment Systems
    Claim Filing and Payment
    Overview of Medicare Fee Schedule Payment Systems
    Private Third-Party Payer and Commercial Fee Schedules
    Payment System Interfaces
    Healthcare Provider Use of Fee Schedules to Set Charges
    Summary and Conclusion
    Healthcare Provider Concepts
    Introduction
    Physicians
    Nonphysician Practitioners and Providers
    Clinics
    Hospitals and Integrated Delivery Systems
    Special Provider Organizations
       DME Suppliers
       Skilled Nursing Facilities
       Home Health Agencies
       Independent Diagnostic Testing Facilities
       Comprehensive Outpatient Rehabilitation Facilities
       Clinical Laboratories
       Ambulatory Surgical Centers
    Summary and Conclusion
    Anatomy of a Fee Schedule Payment System
    Introduction
    Basic Fee Schedule Payment Formula
    Basic Architecture for Healthcare Fee Schedule Payment Systems
    Relative Values
    Classification Systems
    Usual, Customary, and Reasonable
    Claims and the Adjudication Process
    Adjudication Features for Fee Schedules
    Code Sets and Adjudication
    Participating Healthcare Providers
    Chapter Summary
    Medicare Physician Fee Schedule
    Introduction
    Underlying Code Classification Structure
    Payment Amounts under the MPFS
    Elements in the Full MPFS
       CPT/HCPCS Codes
       Modifier
       Description
       Status Code
       Relative Value Units
       Professional Component/Technical Component Indicator
       Global Days
       Pre-Operative, Intra-Operative, Post-Operative Percentages
       Multiple Procedures
       Special Surgical Payment Indicators
       Endoscopic Base Code
       Conversion Factor
       Physician Supervision of Diagnostic Procedures
       Calculation Flag
       Diagnostic Imaging Family Indicator
       Outpatient Prospective Payment System Imaging Cap
    Updating and Modifying the MPFS
    Global Surgical Package
       Overview of Services Included in the GSP
       Pre-Operative Window
       Post-Operative Window
       CPT Modifiers Separating Phases within the Surgery
       Transfer of Post-Operative Care
       Anesthesia Package
    Special Surgical Payment Processes
       Surgical Complications
       Co-Surgeons
       Team Surgeons
       Sequential Surgical Procedures: Separate Physicians
       Staged Surgical Procedures
       Bilateral Surgeries
    Families of Codes
    Nonphysician Practitioners
    Special Utilization of the MPFS
       Independent Diagnostic Testing Facilities
       Comprehensive Outpatient Rehabilitation Facilities
       Critical Access Hospitals
       Ambulatory Surgical Centers
    CPT and HCPCS Modifiers
    National Correct Coding Initiative
        Modifiers Used to Bypass the NCCI Edits
       NCCI Coding Policies
       Medically Unlikely Edits
    Gaining Extra Payment through the MPFS
    Changes and Change Process for the MPFS
       Medicare Secondary Payer
    Using the MPFS RVUs to Establish Charges
    Summary and Conclusion
    Other Medicare Fee Schedule Payment Systems
    Introduction
    Anesthesiology Fee Schedule
    Ambulance Fee Schedule
    Clinical Laboratory Fee Schedule
    Durable Medical Equipment Fee Schedule
    Conclusion and Summary
    Private Third-Party Payer Fee Schedule Systems
    Introduction
    Using Medicare Fee Schedule Approaches
    Usual, Customary, and Reasonable
       Basic Statistical Concepts
       Charge Data
       Statistical Analysis of Charge Data
       UCR Challenges
    Establishing a UCR Schedule of Fee Payments
       Provider-Based Clinics
       Global Surgical Package
       Multiple Surgeries
       Bilateral Surgeries
       Evaluation and Management Services with Surgeries
       Assistants at Surgery
       Co-Surgeons/Multiple Surgeons
       Staged Surgical Procedures
       Surgical Families
       Anesthesia Services
       Mid-level Practitioners
       Physician Supervision
       Edits to Verify Correct Coding
       Extra Payments
       Choosing the UCR Data
       Challenges in Developing Fee Schedule Payment
    Summary and Conclusion
    Appendix: Case Study List
    Acronym List

    Biography

    Duane C. Abbey, PhD, CFP, a nationally recognized expert in payment systems, is president of Abbey and Abbey Consultants, Inc. Dr. Abbey works extensively in all areas relating to coding, billing, and reimbursement with particular emphasis on the chargemaster and outpatient payment. His consulting activities include hospitals, clinics, and physicians. Dr. Abbey. Another special area of expertise includes APGs/APCs. He is recognized as the leading expert in the nation in APGs/APCs by the thousands who have attended his seminars, read his publications, and/or contacted him for his services. Recently, he has begun to turn his focus towards Medicare’s new RAC audits.