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Ch. 3 Hos. Billing
Reimbursemnt Methodologies
| Term | Definition |
|---|---|
| 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
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