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Related Experiment Videos

Calculating pass-through and outlier payments under APCs.

M Gold1, S Snodgrass

  • 1Medtronic, Monsey, New York, USA. martin.gold@medtronic.com

Healthcare Financial Management : Journal of the Healthcare Financial Management Association
|July 27, 2001
PubMed
Summary

Medicare

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Area of Science:

  • Health Economics
  • Medical Device Reimbursement
  • Healthcare Policy

Background:

  • Medicare's outpatient prospective payment system uses Ambulatory Payment Classifications (APCs) for reimbursement.
  • The 1996 cost data used for APC weights do not reflect current innovative medical technologies.
  • This outdated data impacts accurate reimbursement for new devices, drugs, and biologics.

Purpose of the Study:

  • To explain the need for updated payment systems for innovative medical technologies in outpatient settings.
  • To highlight the importance of the Balanced Budget Refinement Act of 1999 (BBRA) in addressing these payment gaps.
  • To emphasize the necessity for financial managers to understand new medical products for accurate billing.

Main Methods:

  • Analysis of Medicare's outpatient prospective payment system structure.
  • Review of the Balanced Budget Refinement Act of 1999 (BBRA) provisions.
  • Identification of challenges in cost-based reimbursement for new medical items.

Main Results:

  • The existing APC system's reliance on historical data leads to underreimbursement for innovative medical devices, drugs, and biologicals.
  • The BBRA introduced transitional pass-through payments and cost-outlier adjustments to address these discrepancies.
  • Accurate financial management requires detailed knowledge of current outpatient surgical department technologies.

Conclusions:

  • The BBRA's pass-through and outlier payment systems are crucial for accommodating the costs of new medical innovations.
  • Financial managers must stay informed about evolving medical devices, drugs, and biologics for effective reimbursement.
  • Updated financial strategies are essential to ensure adequate compensation for advanced medical treatments under Medicare.

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