Ch. 8-Medicare Physican and Other Health Professional Payment System Flashcards
Alternative payment model (APM)
Payment approach that provides added incentives to deliver high-quality and cost-efficient care
Assignment of benefits
A contract between a physician and Medicare in which the physician agrees to bill Medicare directly for covered services, to bill the beneficiary only for any coinsurance or deductible that may be applicable, and to accept the Medicare payment as payment in full.
Medicare usually pays 80% of the approved amount directly to the provider of services after the beneficiary meets the annual part B deductible. Beneficiary pays the other 20% (coinsurance)
Geographic practice cost index (GPCI)
Index based on relative difference in the cost of a market basket of goods across geographic areas. A separate GPCI exists for each element of the relative value unit (RVU) which includes physician work, practice expenses, and malpractice. GPCIs are a means to adjust the RVUs, which are national averages, to reflect locals costs of services
Health professional shortage areas (HPSA)
Areas that have a shortage of providers in medical care, dental care, or mental health, or some combination of these as designed by the US Health Resources and Service Administration
Incident to
Services provided by non-physician clinicians, such as a nurse or physician assistant, that are delivered to patients in a physician’s offices under the physicians direct supervision
Malpractice (MP) element
Element of the relative value unit (RVU); cost of the premiums for malpractice insurance and professional liability insurance
Medicare physician fee schedule (MPFS)
The maximum amount of reimbursement that Medicare will allow for a service; consists of a list of payments for services defined by a service coding system (for example- HCPCS)
Nonparticipating physician (nonPAR)
Physicians who treat Medicare beneficiaries but do not have a legal agreement with the program to accept assignment on all Medicare services and who, therefore, may bill beneficiaries more than the Medicare reasonable charge on a service-by-service basis. Nonparticipating physicians receive 95% of the full Medicare physician fee schedule amount
Participating physician (PAR)
Physician who signs an agreement with Medicare to accept assignment for all services provided to Medicare beneficiaries for the duration of the agreement
Physician work (WORK) element
Element of the relative value unit(RVU) that should cover the physician’s salary. This work is the time the physician spends providing a service and the intensity with which that time is spent.
Four elements of intensity: mental effort and judgement, technical skill, physical effort, and psychological stress
Practice expense (PE) element
Element of the relative value unit (RVU) that covers the physicians overhead costs, such as employee wage, office rent, supplies, and equipment.
Two types: facility and nonfacility
Quality Payment Program (QPP)
Payment incentive program for physician and eligible clinicians that links physician to quality measures and cost-saving goals
Relative value unit (RVU)
Unit of measure designed to permit comparison of the amount of resources required to perform various provider services by assigning weights to such factors as personnel time, level of skill, and sophistication of equipment required to render service.
In resource-based relative value scale (RBRVS), the RVU reflects national averages and is the sum of the physician work, practice expenses, and malpractice
Resource-based relative value scale (RBRVS)
Resource management system that assigns values to services performed by physicians and other health professionals based on the cost of furnishing services in different settings, the skill and training levels required to perform the services, and the time and risk involved
