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Ch. 3 Hos. Billing

Reimbursemnt Methodologies

TermDefinition
Ambulatory Payment Classification (APC) utilized by Medicare and other carriers for outpatient facility reimbursement. Facilities are paid based on fixed fee based on procedures provided by the facility.
Capitation Generally utilized by managed care plans. Methodology is based on a monthly per-member-per-month (PMPM) fee for each enrolled member.
Case Rate Set rate paid to the facility for the entire case
Contract Rate Set rate as agreed upon in a pre-agreed-upon contract
Diagnosis Related Group (DRG) Inpatient reimbursement methodology where the facility is paid a fixed fee for the patient's diagnosis or condition
Fee-for-Service Fee scheduled for each service medically necessary and provided by facility
Flat Rate Reimbursement methodology is based on a set rate per each admission, regardless of total charges.
Per Diem Set rate per day
Resource- Based Relative Value Study Each code/ procedure is assigned a set value that is comprised of multiple components, such as physician time, skill, practice overhead, and malpractice
Usual, Customary, and Reasonable (UCR) Reimbursement is based on usual fee, customary fee, and reasonable fee, whichever is less
Created by: Dhernandez95