Outpatient Service Case Study

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1. Discuss the difference in Medicare payment methods for outpatient services and physician services. The outpatient services provide the following information about the Hospital Outpatient Prospective Payment System (OPPS). On August 1, 2000, the Centers for Medicare & Medicaid Services (CMS) began using the OPPS, which was authorized by Section 1833(t) of the Social Security Act (the Act) as amended by Section 4533 of the Balanced Budget Act of 1997. The OPPS was implemented in calendar year (CY) 2000 and pays for designated hospital outpatient services (Figure 1- UB04 bill) , certain Medicare Part B services furnished to hospital inpatients when Part A payment cannot be made; partial hospitalization services furnished by hospitals or…show more content…
Challenges associated with it include the difficulty of defining the boundaries of an episode (what care falls within and outside of the episode); its potential to increase barriers to patients’ choice of provider and/or geographic preferences for care if adoption is not widespread; lack of incentive to reduce unnecessary episodes; and the potential to avoid high-risk patients or cases that may exceed the average episode…show more content…
The challenges associated with it include the difficulty of defining the boundaries of an episode (what care falls within and outside of the episode); its potential to increase barriers to patients’ choice of provider and or geographic preferences for care if adoption is not widespread; lack of incentive to reduce unnecessary episodes and the potential to avoid high-risk patients or cases that may exceed the average episode payment (Silversmith, J., 2011). For example, Geisinger Health System’s ProvenCare: as a bundled payment model for coronary artery bypass graft (CABG) surgery (AHA, 2010). This appears to be a case rate in which the hospital and the professional fees were each paid a single fee for inpatient and physician services during hospitalization. In the essence there is warranty period of coverage if there is readmission within 72 hours and the patient is covered when the patient comes back for complications within that time period, all services are covered and the patient would not need to pay any additional money for hospitalization. Furthermore, since CABG is

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