Reimbursement 101 2011 - Cardinal Health

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Reimbursement-Drugs used in Nuclear Medicine HOPPS: Under HOPPS if Medicare has determined that the average cost t of f a drug d exceeds d a th threshold h ld of f $70 th then separate t payment is made; otherwise it is bundled and no separate payment is made Payment rates are listed in the HOPPS payment tables – Examples of drugs separately paid: Lexiscan, adenosine MPFS: Drugs are paid separately based on average selling price (ASP) Medicare publishes an ASP Pricing file with the payment rates and updates the file quarterly; there is no minimum threshold 20 © Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Reimbursement - Private Payers 21 • Payments depend on the payers contract with the provider. Common arrangements include: • Negotiated fee schedule – services paid at a set rate • Discounted charges – negotiated percent discount off provider charges • Capitation – specified amount of money paid into a health plan to cover the cost of a health plan member’s health care services for a specific amount of time. A contracted amount of money is paid based on membership rather than the number of services rendered. • RPs and drugs typically paid separately; however payment methodology varies among the private payers © Copyright 2011, Cardinal Health, Inc. or one of its subsidiaries. All rights reserved.
Page 1 and 2: Nuclear Medicine Reimbursement 101
Page 5 and 6: Reimbursement Terminology 5 • HCP
Page 7 and 8: Reimbursement Terminology 7 • HOP
Page 9 and 10: NM Reimbursement 101 > A/B MACs 9
Page 11 and 12: A/B Medicare Administrative Contrac
Page 13 and 14: NM Reimbursement 101 > A/B MACs 13
Page 15 and 16: NM Reimbursement 101 15 © Copyrigh
Page 17 and 18: Reimbursement - Hospital Outpatient
Page 19: Reimbursement - RP in Clinic Settin
Page 23 and 24: Coverage • Most important issue i
Page 25 and 26: Coverage - Private Payers • Incre
Page 27 and 28: Coverage - Medicare A service or pr
Page 29 and 30: Coverage - Medicare 29 • In gener
Page 31 and 32: CMS Coverage with Evidence Developm
Page 33 and 34: PET Coverage > Medicare Medicare Na
Page 37 and 38: Coding 37 • ICD-9-CM - Internal C
Page 39 and 40: Coding 39 CPT/HCPCS codes • The n
Page 41 and 42: Coding Modifiers • Two character
Page 43 and 44: Coding - Hospital Revenue Codes •
Page 45 and 46: Coding > Claim Forms • Hospitals
Page 47 and 48: Coding > Claim Form 1450 (Hospital)
Page 53 and 54: Coding > Claim Form 1500 Clinic/Phy
Page 55 and 56: NM Reimbursement 101 - References 5
Page 57 and 58: NM Reimbursement 101 - References h

Reimbursement 101 2011 - Cardinal Health

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