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A prospective payment system ( PPS) is a term used to refer to several payment methodologies for which means of determining insurance reimbursement is based on a predetermined payment regardless of the intensity of the actual service provided. It includes a system for paying hospitals based on predetermined prices, from Medicare.
APCs or Ambulatory Payment Classifications are the United States government's method of paying for facility outpatient services for the Medicare (United States) program. A part of the Federal Balanced Budget Act of 1997 made the Centers for Medicare and Medicaid Services create a new Medicare "Outpatient Prospective Payment System" (OPPS) for hospital outpatient services -analogous to the ...
Because the [Outpatient Prospective Payment System] payment rates for drugs furnished to hospital outpatients are the same for all hospitals without regard to whether the drugs were purchased through the 340B program, hospitals have an incentive to increase margins by expanding their patient base for chemotherapy administration.
The Supreme Court ruled that the changes to the drug payment policy of the Hospital Outpatient Prospective Payment System were unlawful, so to compensate for the reimbursement issues, the CMS ...
Diagnosis-related group. Diagnosis-related group ( DRG) is a system to classify hospital cases into one of originally 467 groups, [1] with the last group (coded as 470 through v24, 999 thereafter) being "Ungroupable". This system of classification was developed as a collaborative project by Robert B Fetter, PhD, of the Yale School of Management ...
The National Correct Coding Initiative (NCCI) is a Centers for Medicare & Medicaid Services (CMS) program designed to prevent improper payment of procedures that should not be submitted together. There are two categories of edits: Physician Edits: these code pair edits apply to physicians, non-physician practitioners, and Ambulatory Surgery ...
For institutional care, such as hospital and nursing home care, Medicare uses prospective payment systems. In a prospective payment system, the health care institution receives a set amount of money for each episode of care provided to a patient, regardless of the actual amount of care.
CMS sets fee schedules for medical services through Prospective Payment Systems (PPS) for inpatient care, outpatient care, and other services. As the largest single purchaser of medical services in the U.S., Medicare's fixed pricing schedules have a significant impact on the market.