Medicare Reimbusement Rates

Hospital Outpatient Prospective Payment System

Background

More than 4,000 hospitals, including general acute care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, long-term acute care hospitals, children’s hospitals, and cancer hospitals are paid under the HOPPS.  There are approximately 5,000 Medicare-participating ASCs paid under the ASC payment system.

The HOPPS is currently a hybrid of a prospective payment system and a fee-for-service system, with some payments representing costs packaged into a primary service and other payments representing the cost of a particular item, service, or procedure.  Payment amounts vary according to the Ambulatory Payment Classification (APC) group to which a service is assigned.  The HOPPS includes payment for most hospital outpatient department services, and covers partial hospitalization services furnished by hospital outpatient departments and community mental health centers.

Current Status

On January 27, 2014, SNMMI submitted comments on the CY 2014 HOPPS Final Rule.

 



Medicare Physician Fee Schedule

Background

The Medicare Physician Fee Schedule (MPFS) sets reimbursement rates which affects physicians and office payment for services paid under the resource based relative value scale (RBRVS). Prior to the use of this schedule, which began in 1992, charges for services were based on customary, prevailing and reasonable charges. With the implementation of MPFS, charges were intended to be based on resource costs required to provide the services. The MPFS pricing amounts are adjusted to reflect the variation in practice costs from area to area. A geographic practice cost index (GPCI) has been established for every Medicare payment locality for each of the three components of a procedure's relative value unit (RVU). The GPCIs are applied in the calculation of a fee schedule payment amount by multiplying the RVU for each component times the GPCI for that component.

Current Status

On January 27, 2014, SNMMI submitted comments on the CY 2014 MPFS Final Rule.


More information on the HOPPS and MPFS can be found at SNMMI's Coding Corner.