Medicare reimbursement and case mix

For hospitals, health systems and other providers, it has been the most influential healthcare program for the industry in recent decades. Medicare continues to play a prominent part in various reform movements, such as the shift from fee-for-service to value-based payments and the push for greater price transparency. The program's pay rates and policies have the potential to act as a catalyst for change nationwide, or to provoke coast-to-coast controversy as has been the case with the new two-midnight rule. The following list sheds some light on the many facets of and issues surrounding Medicare reimbursement in the form of things to know, covering everything from the latest update to the Inpatient Prospective Payment System to the Bundled Payments for Care Improvement Initiative.

Medicare reimbursement and case mix

If you choose not to associate with Medicare in any capacity, you cannot treat—or collect payment from—Medicare patients for any Medicare-covered services. You can, however, treat Medicare patients on a cash-pay basis for non-covered services, which I will discuss in greater detail below.

Enrolled as a participating provider.

Should Physical Therapists Enroll as Medicare Providers? | WebPT

If you decide to participate in Medicare, you must bill Medicare for all covered therapy services that you provide to Medicare beneficiaries—even if you believe Medicare will deny the claim. Thus, you cannot collect cash payment for such services directly from a patient—even if the patient wants to pay cash.

With this type of relationship, you can still collect cash payment for services Medicare will not cover, either due to statutory exclusion i. If the patient would like to pay out-of-pocket for non-medically necessary services, you must issue an advance beneficiary notice of noncoverage ABNwhich serves as a record that the patient agrees to accept financial liability in the event that Medicare denies payment.

If the patient would like to pay out-of-pocket for non-covered therapy services, no ABN is required. However, you do have the option of issuing a voluntary ABN, or a similar consent form, as a courtesy to the patient.

Enrolled as a non-participating provider. This means that you can collect cash-payment from Medicare patients for covered services that you provide, but as you will see on this Medicare.

The provider can then bill the patient directly. On a side note, you can make your voice on this issue heard by visiting this APTA advocacy page. But the following excerpt sums up the gist of it: To help both physical therapists and payers better understand and apply the concept of medical necessity as it relates to therapy services, the APTA adopted the Defining Medically Necessary Physical Therapy Services position in That is the Question For most PTs, the number-one drawback to treating Medicare patients is the combination of shrinking reimbursements—due to initiatives such as Multiple Procedure Payment Reduction MPPR —and ever-increasing regulations and compliance requirements.

Medicare reimbursement and case mix

CMS is demanding more and more from us: PQRS, functional limitation reporting, onerous documentation standards, and post-treatment audits.

Many are considering dropping Medicare patients. Most want to continue to treat this needy population, but are concerned about the fiscal and frustration implications. Carter, you need to ask yourself: Is your practice located in an area where the majority of people seeking PT are over the age of 64?

Could you generate enough business if you did not accept Medicare patients? For a quick lesson on how to calculate your Medicare payer mix percentage and your average revenue per Medicare visit, check out this blog post. Based on these metrics, if you know your practice would struggle to survive sans Medicare, then you will definitely want to enroll—either as a participating provider or a non-participating provider.

If you go the non-participating route, keep in mind that some patients may be hesitant to pay for services upfront if they can get those services from a participating provider without having to pull out their own checkbooks.

Another scenario in which it might make sense to be a non-participating provider, according to Dr. Just make sure the demographics of your customer base support that decision. Does your practice currently participate in Medicare?

Will you continue to do so for the foreseeable future? Why or why not?


Share your thoughts in the comment section below.Federal Register/Vol. 82, No.

Strategic Reimbursement Group, LLC - Third Party Healthcare Specialists

/Tuesday, November 7, /Rules and Regulations DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services 42 CFR Part [CMS––F] RIN –AT01 Medicare and Medicaid Programs; CY. The financial department monitors case-mix index (CMI), and in an ideal world, the hospital’s CMI would be as high as possible.

A high CMI means the hospital performs big-ticket services and therefore receives more money per patient. If you’re starting—or have ever started—a private physical therapy practice, then you’ve almost certainly grappled with the decision of whether to accept Medicare patients.

And unless your patient demographic absolutely demands that you do, I’m guessing it is—or was—a pretty tough call. PAYMENT OF BENEFITS.

Sec. [42 U.S.C. l] Except as provided in section , and subject to the succeeding provisions of this section, there shall be paid from the Federal Supplementary Medical Insurance Trust Fund, in the case of each individual who is covered under the insurance program established by this part and incurs expenses for services with respect to which benefits are.

-Case-mix levels must be considered -Hospital costs could be controlled while still providing adequate reimbursement T-hose systems which worked the best were those which were strictly enforced. It's often said that where Medicare goes, private payers will follow. For hospitals, health systems and other providers, it has been the most influential healthcare program for the industry in.

Medicare case-mix index increase