How can physicians and other health professionals increase reimbursements with RBRVS?
By increasing the volume of services provided to a patient (Exp. payment for office visit, drawing labs, running an EKG etc).
With RBRVS what is reimbursement based on?
The CMS estimation of the value of a physician's service and the fees are pre-determined.
Dr. William Hsaio developed what type of system for payment that became effective January 1, 1992?
Fee-for-service system of payment
In 1985 under a grant from CMS (formally HCFA), what was devised?
A system of classifying health services using resourced-based relative values.
With RBRVS (Resource-based relative value scale for Physician and Professional Payments) payments to physicians are based on what three components?
RVU (Relative value unit), Its geographic adjustment (where the service is rendered, i.e. rural or city), CF (A conversion factor)
The RBRVS is based on ___?
HCPCS (Healthcare Common Procedure Coding System) and includes CPT (Current Procedural Terminology).
Each HCPCS/CPT code has been assigned ?
an RVU (Relative-value unit)
Define a relative-value unit (RVU).
A unit of measure designed to permit comparison of the amounts of resources required to perform various provider services by assigning weights to such factors as personnel time, level of skill, and sophistication of equipment required to render service.
Each RVU (relative-value unit ) is subdivided into three elements. Each element has a unique weight. The weight of these elements are summed to calculate the RVU weight. What 3 things make up the RVU weight?
Physician work (WORK), Physician practice expense (PE), Professional liability insurance (PLI) or Malpractice (MP)
What is Physician Work (WORK) ?
The element that covers the physician’s salary. This work is the time the physician spends providing a service and the intensity with which that time is spent.
What are the four aspects of intensity of service (Physician work)?
Mental effort and judgment, Technical skill, Physical effort, Psychological stress.
What is Practice Expense (PE), and how many categories are there of PE costs?
The overhead cost of the practice. Six.
What are the six categories of Practice Expense (PE)?
Clinical Payroll - Administrative Payroll - Office expenses - Medical material & supply expenses for drugs, x-ray films, disposable medical products, and other related costs - Medical Equipment - All other expenses such as legal services, accounting, office management, professional association memberships, and any professional expenses.
What does CMS base the Malpractice (MP) element of the RVU (Relative Value Unit) on ?
The premiums for malpractice insurance.
RVU's are routinely maintained to keep them up-to-date, CMS analyst must review RVU's how often ?
At least once every five years to ensure the accuracy of the weights.
What is a Conversion Factor (CF)?
An across-the-board multiplier.
A Conversion Factor (CF) is constant & applies to the entire RVU (relative-value unit), it is the government's most direct control of what ?
Medicare's payments to physicians and other professionals.
Why does CMS raise or lower the CF (Conversion Factor) ?
To raise or lower physician and other professionals payments.
CMS updates the CF _____ and publishes the amount in the ____ ______.
Annually, Federal Register.
Potential Adjustments may be ____?
Special circumstances via CPT modifiers (Bilateral, Multiple procedures).
Regarding Operational Issues: What may effect payment (i.e. cause an underpayment)?
Poor coding or inadequate documentation.
Operational Issues: Impact of _____?
Unnecessary Administrative Costs (Time spent on administrative details for multiple health plans, Sources of administrative waste.
What are sources of administrative waste?
Varying processes (i.e. Prior authorization, Billing requirements, Claims submission & adjudication procedures), Unique policies & rules for each health plan.
** What is RBRVS (Resource-based relative value scale for Physician and Professional Payments)?
A payment system specific to physician and other health professional services across the continuum of care.
** RBRVS (Resource-based relative value scale for Physician and Professional Payments) as a discounted fee schedule, is a ?
Fee-for-Service payment system (not a PPS)
** RBRVS comprises of what three components?
RVU (Relative Value Unit), GPCI (Geographic Practice Cost Index), and CF (Conversion Factor)
** Why is accurate coding and complete documentation so important?
It is necessary for appropriate reimbursement.
What happened in 1983?
Medicare moved to a PPS (Prospective Payment System) for hospital inpatient services.
Why did Medicare move to a PPS (Prospective Payment System) for hospital inpatient services?
To help control increasing healthcare costs and Medicare expenditures
As CMS experienced cost savings & reduced expenditures for inpatient services they made efforts to incorporate these concepts into other healthcare settings, after 13 years CMS implemented what other PPS ?
OPPS (Outpatient prospective payment system) on August 1, 2000.
Before the implementation of OPPS (Outpatient prospective payment system), Medicare payment for hospital outpatient services was based ______ .
As healthcare costs continued to rise, why did CMS move toward a PPS (Prospective Payment System)?
To encourage a more efficient delivery of care for outpatient beneficiaries.
** Reimbursement for outpatient services uses what three methods?
Fee Schedules - Prospective Payment - Cost Based.
** What is the primary standard that distinguishes a PPS from a fee schedule?
With PPS the costs for certain items and secondary services associated with a primary procedure are packaged into the payment for that procedure. A fee schedule system establishes a separate payment amount for each item or service and no packaging occurs.
Regarding PPV vs. Fee Schedule, most procedures & services are reimbursed ?
Under APC's (Ambulatory Payment Classification), which is the PPS part of the Outpatient system.
How are Ambulance transportation, physical therapy, occupational therapy, and speech-language pathology reimbursed?
Via various fee schedules.
Molecular pathology and surgical pathology laboratory services are paid how?
Via the clinical diagnostic laboratory fee schedule.
OPPS (Outpatient Prospective Payment System) requires that facilities use Level I and II HCPCS codes to report ___ ?
Services/procedures performed and items/supplies provided for beneficiaries (in the outpatient arena).
** Each code in HCPCS has been assigned what ?
A payment status indicator.
** What does the payment status indicator establish ?
How that service, procedure, or item is paid (by fee schedule, APC, reasonable cost, or unpaid).
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