Reimbursemnt Methodologies
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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.
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Capitation | Generally utilized by managed care plans. Methodology is based on a monthly per-member-per-month (PMPM) fee for each enrolled member.
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Case Rate | Set rate paid to the facility for the entire case
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Contract Rate | Set rate as agreed upon in a pre-agreed-upon contract
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Diagnosis Related Group (DRG) | Inpatient reimbursement methodology where the facility is paid a fixed fee for the patient's diagnosis or condition
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Fee-for-Service | Fee scheduled for each service medically necessary and provided by facility
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Flat Rate | Reimbursement methodology is based on a set rate per each admission, regardless of total charges.
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Per Diem | Set rate per day
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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
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Usual, Customary, and Reasonable (UCR) | Reimbursement is based on usual fee, customary fee, and reasonable fee, whichever is less
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