MCCG212 – Reimbursement Methodology Report Template
2
Reimbursem
ent System
Outpatient
Surgery
Center
Hospital
Inpatient
Laboratory
Services
Prescription
Drug Medicare
Hospital Outpatient Prospective Payment System
(OPPS) is the system through which Medicare decides how much money a hospital or community mental health center will get
for outpatient care provided to patients with Medicare. The rate of reimbursemen
t varies with the
location of the
hospital or clinic.
Inpatient Prospective Payment System
(IPPS). Under the IPPS, each
case is categorized into a diagnosis related group (DRG). Each DRG
has a payment weight assigned to it, based on
the average resources used to treat Medicare patients in that DRG.
Laboratory fee
schedule
A manufacturer'
s average sales price (ASP)
Medicare
Advantage
(Managed
Care) Part C
HMO or PPO
HMO or PPO
Laboratory fee
schedule
Medicare Part D only covers prescription drugs.
Medicaid
Fee-For-
Service (FFS) model. FFS rates are designed to pay doctors only for the care that Fee-For-
Service and Medicaid Managed Care
Laboratory fee
schedule
A manufacturer'
s average sales price (ASP)
