Under different settings, Medicare pays varying amounts for most comparable services provided by the facility-related component. The state and federal government implement numerous changes to healthcare payment policies in a bid to improve them. The reimbursement systems for physicians and ambulatory settings have undergone significant changes to ensure they adapt to the needs of patients and allow effective operation of healthcare facilities.
Reimbursement Systems for Physicians and Ambulatory Settings
Ambulatory settings use separate payment systems to ensure Medicare beneficiaries get care. These include physician offices (POs), ambulatory surgical centres (ASCs) and hospital outpatient departments (HOPDs). The payment policy changes were implemented in 2008, setting ASC payment rates at 67 percent for most procedures. There has been much standardization of reimbursement systems between ASCs and HOPDs. There is a chance that these reimbursement systems may vary over time because of separate budget-neutrality and different conversion factor update method for recalibration of the relative weights. A wide variation of the reimbursement rate also exists for similar services between POs and ASCs/HOPD with the differential size varying by service (Casto & Forrestal, 2013).
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However, the measurement of these differentials is problematic due to the variations of related services, which are typically packaged into reimbursement payments for particular procedures performed by physicians. Medicare reimbursement payments are generally higher than private reimbursement payment. Cost differentials between PO stings and HOPD setting are also large (Davidson et al., 2013). Furthermore, study methods across ambulatory settings differ in terms of distribution with ASC receiving lower percentage services while PO setting has a higher percentage of non-Medicare patients.
In conclusion, patients are usually referred to as the HOPDs due to their comorbidity. The clients who are at low risk of adverse outcomes in ambulatory settings are those receiving the study procedures. However, the ones who require resource-intensive procedures might be refereed most often to HOPD since the payment rate is professed inadequate to cover the PO/ASC setting costs of providing care.
References
Casto, A. B., & Forrestal, E. (2013). Principles of healthcare reimbursement . American Health Information Management Association.
Davidson, T., Rohlin, M., Hultin, M., Jemt, T., Nilner, K., Sunnegårdh-Grönberg, K., ... & Nilsson, M. (2015). Reimbursement systems influence prosthodontic treatment of adult patients. Acta Odontologica Scandinavica , 73 (6), 414-420.
