The PFFS Reimbursement Guide SecureHorizons Direct reimburses claims based on Medicare Fee Schedules, Prospective Payment Systems (PPS) and estimated Medicare payments amounts, in accordance with Code 42.C.F.R., Section 422.114.
Providers may contact SecureHorizons Direct SM for claims reimbursement questions and to check the status of a claim previously submitted for reimbursement at 1-866-579-8811. Acute Care Hospital-Inpatient Services Reimbursements for these services are at the Prospective Payment System (PPS) under the Diagnosis Related Groups (DRGs) methodology. This methodology includes any appropriate capital disproportionate share hospital (DSH), capital indirect medical education (IME) payments and special payment adjustments to Medicare dependent hospitals (MDH) and sole community hospitals (SCH) when applicable. Organ acquisitions at a Medicare approved transplant facility are reimbursed on a cost basis. The following costs are fully carved out from SecureHorizons Direct reimbursement. The hospital should submit a duplicate claim to the FI for reimbursement for these services: Operating IME costs Graduate medical education (GME) Pass-through payments for capital exceptions, CRNAs, costs associated with nursing school, and Allied health education programs Acute Care Hospital-Inpatient Outliers Acute Care Hospital- Outpatient Services Ambulance Ambulatory Surgery Center Anesthesia/Physician Performed Reimbursement for outlier services is 80% of the excess of the cost of an admission over the sum of the DRG payment (including capital IME and DSH) and a threshold amount. SecureHorizons Direct will follow the current Medicare threshold guidelines. Reimbursement for these services is based on the Outpatient Prospective Payment System (OPPS), under Ambulatory Payment Classifications (APCs). These services are reimbursed at 100% of the National Medicare Fee Schedule for CY 2006. Reimbursement for services at an Ambulatory Surgical Center is based on the ASC Fee Schedule. Reimbursement for these services is based on the Medicare anesthesia dollar conversion factor by locality, times the sum of uniform base units, plus time units. 1
Anesthesia-Physician Medical Direction of 2 or more Nurse Anesthetists concurrently Assistant surgeon (physician) Assistant surgeon (physician assistant) Bad Debts (facilities) Blood Braces Cancer Hospitals-Inpatient Cancer Hospitals-Outpatient Reimbursement for these services is based on the Medicare anesthesia conversion factor by locality, times the sum of uniform base units, plus time units, reduced by 50% of the allowance for the service performed by the physician. The allowable charge for this service is 16% of the amount applicable for global surgery under the Medicare Fee Schedule. The allowable charge for this service is 85% times 16% of the amount paid to a physician who serves as an assistant at surgery. The Plan will only pay for bad debt on copayments and coinsurance that the enrollee is directly responsible to pay. Bad debt reimbursement will only occur after a facility has made reasonable attempts to collect from the enrollee. Bad debt reimbursement will occur if 120 days have elapsed since the date of service without collection of the enrollee s copayment or coinsurance. The facility must submit a copy of a bill demonstrating an outstanding balance and 120 days delinquency. Hospitals receive 70% of bad debt; other facilities receive 100% of bad debt, including: SNFs, Rural Health Clinics, FQHC's, and Community Mental Health Clinics and ESRD facilities: bad debts are capped so that the reimbursement does not exceed the facility s costs. Reimbursement for blood is based on the OPPS for hospital outpatient services. Braces are covered when furnished incident to physicians' services or on a physicians' order. Reimbursement is at the Medicare Allowable Charge on the Medicare Durable Medical Equipment, Prosthetic, Orthotic and Supplies (DMEPOS) Fee Schedule. These services are exempt from the inpatient PPS. Cost-based reimbursement is paid on a per-day basis for routine and ancillary services and based on the most recent cost report data. Payment is applicable to Medicare approved services only. Reimbursement for these services is based on the Outpatient Prospective Payment System (OPPS), under Ambulatory Payment Classifications (APCs). 2
Children's Hospitals-Inpatient Children's Hospitals- Outpatient Clinical Nurse Specialist Clinical Psychologist Clinical Social Worker Clinical Trial Services Community Mental Health Centers CORF Co-Surgeons Critical Access Hospitals Diabetic Shoe These services are exempt from the inpatient PPS, and reimbursement is cost-based. Routine services and ancillary services are reimbursed on a per diem basis. Ancillary services reimbursement is based on the most recent cost-report data. Reimbursements for these services are based on OPPS under Ambulatory Payment Classifications (APCs). Reimbursement is at 85% of the Medicare Allowable Charge on the Medicare physician Fee Schedule for comparable services. Reimbursement is at 100% of the Medicare Allowable Charge on the Medicare physician Fee Schedule for comparable services for administering diagnostic psychological tests and supervising the administration of these tests. Reimbursement is at 75% of the Medicare Allowable Charge on the Medicare physician Fee Schedule for comparable services. Medicare directly reimburses all approved clinical trial services provided to Medicare Advantage enrollees according to the appropriate fee for service methodology. Reimbursement for these services is based on the OPPS, under Ambulatory Payment Classifications (APCs). Medicare physician Fee Schedule. Vaccines are reimbursed at 95% AWP. Reimbursement for each co-surgeon is 62.5% of the global surgery rate under the Medicare physician Fee Schedule. Reimbursement is at 102% of the facility s most recent interim rate letter. The additional compensation is in lieu of the year-end settlement under the SecureHorizons Direct plan. The facility can proactively send a copy of its most recent interim rate letter from the Medicare Fiscal Intermediary to SecureHorizons Direct, at the claims address. Or, SecureHorizons Direct will contact the facility for a copy of the most recent interim rate letter upon receipt of a claim. The reimbursement rate is at the Medicare Allowable Charge on the Medicare DMEPOS Fee Schedule. 3
Drugs Durable Medical Equipment Epoetin (EPO) ESRD Facility Federally Qualified Health Centers Hemophilia clotting factors billed by provider (eg. Hosp, SNF, HHA) Hemophilia clotting factors billed by supplier (e.g. DME supplier, independent pharmacy, Red Cross) Home Dialysis Supplies & Equipment Home Health Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. These services are reimbursed at the Medicare Allowable Charge on the Medicare DMEPOS Fee Schedule. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. The reimbursement is the composite rate based on the facility location, metropolitan statistical area (MSA) or non-msa and whether the facility is provider-based or independent. Non-routine services are reimbursed based on the appropriate fee schedule. FQHC reimbursement is 80% of the lower of the all inclusive rate or the upper limit; plus 20% of the FQHC's actual charge. The 2006 Urban FQHC upper payment limit per visit is $112.96 and the 2006 Rural FQHC upper payment limit is $97.13. The facility can proactively send a copy of its most recent interim rate letter from the Medicare Fiscal Intermediary to SecureHorizons Direct, at the claims address. Or, SecureHorizons Direct will contact the facility for a copy of the most recent interim rate letter upon receipt of a claim. Reimbursement for services provided during inpatient care is an add-on payment. Services provided in an outpatient setting will be reimbursed on a cost basis. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. Reimbursement is according to Method I or Method II per Medicare Fee Schedules. Reimbursement for these services is based on PPS, under home health resource groups (HHRGs) methodology. Providers are reimbursed per 60 day episode via submission of a request for accelerated payment (RAP) and claim submission. Reimbursement includes adjustments for low utilization payment adjustment (LUPA), significant change in condition (SCIC), partial episode payment (PEP), therapies and outliers. Limited services are reimbursed under OPPS. DME is reimbursed at the DMEPOS Fee Schedule. 4
Home Infusion Hospital Transfer Acute to Acute Hospital Transfer Acute to Post-Acute Health Professional Shortage Area (HPSA) Immunosuppressive Drugs, transplant Indian Health Service Facility (HIS)-inpatient services Indian Health Service Facility (HIS)-outpatient services Injections Reimbursement is based on the Medicare DMEPOS Fee Schedule for applicable services. The full DRG amount is paid to the final discharging hospital and each transferring hospital is paid a per diem rate. The per diem rate is the full DRG amount that would have been paid in a nontransfer situation, divided by the geometric mean length of stay for the DRG. Reimbursement is calculated as either twice the per diem for the first day plus the per diem for each following day up to the transfer or the full DRG amount. A qualified discharge from one of the 29 DRGs to a post-acute care provider will be treated as a transfer case. The per diem rate is the full DRG amount that would have been paid in a nontransfer situation, divided by the geometric mean length of stay for the DRG. Total reimbursement is calculated as both twice the per diem for the first day and the per diem for each following day up to the transfer, or the full DRG amount. DRGs 209, 210 and 211 are paid under a methodology where 50% of the DRG plus the per diem is paid on the first day of the stay. For each subsequent day, 50% of the per diem is paid up to the full DRG amount. Reimbursement is at the Medicare physician Fee Schedule for comparable services plus a 10% bonus for health professionals in a designated HPSA. Reimbursement is according to OPPS if the enrollee is in the outpatient department of a Medicare participating hospital. In all other settings reimbursement is at 85% average wholesale price (AWP). Reimbursements for these services are based on the Prospective Payment System (PPS) under the DRG methodology. Reimbursement is excluded from the OPPS and is based on an all-inclusive rate. Outpatient professional services are reimbursed based on their respective fee schedules. Physicians can also be reimbursed for injections and vaccinations even when performed on the same day as other Medicare covered services. 5
Laboratory Long Term Care Hospitals (LTCH) Low Volume Hospitals Mammography Screening Maryland Hospitals Medical Nutrition Therapy Nurse Practitioner Oral Anti-Cancer Drugs Oral Anti-Nausea Parenteral and Enteral Nutrition (PEN) Physical, Occupational, Speech Therapist Physician Assistant Physician Scarcity Area (PSA) Medicare laboratory Fee Schedule. LTCH PPS (DRGs) are effective for cost reporting periods beginning on or after 10/01/02. Reimbursement is subject to a five year blend in 20% increments unless the LTCH elects to be paid based on 100% Federal PPS rate. Short stay and high cost outliers apply. If a hospital has fewer than 800 discharges per year, and is more than 25 miles from the closest acute care hospital, the facility will be reimbursed an additional payment not to exceed 25%. Medicare physician Fee Schedule. Reimbursement is at 94% of approved charges for inpatient and outpatient services. Reimbursement is at 85% of the Medicare Allowable Charge on the Medicare physician Fee Schedule. Reimbursement is at 85% of the Medicare Allowable Charge on the Medicare physician Fee Schedule. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. Drugs not paid on a cost or prospective payment basis will be paid under the new ASP (average sale price) drug payment system. Reimbursement is based on the PEN Fee Schedule. Medicare physician Fee Schedule. Reimbursement is at 85% of the Medicare Allowable Charge on the Medicare physician Fee Schedule. Medicare physician Fee Schedule plus a 5% bonus for physicians in a PSA. 6
Physician Services (Audiologist) Physician Services (Chiropractor) Physician Services (Dentist) Physician Services (DO) Physician Services (MD) Physician Services (Optometrist) Physician Services (Oral and Maxilofacial Surgeon) Physician Services (Podiatrist) Prosthetic Devices Medicare DMEPOS Fee Schedule. 7
Psychiatric Hospitals-Inpatient For hospital fiscal years beginning after 1/1/05, the reimbursement will be a blend of 75% of the old TEFRA reimbursement and 25% of the new PPS reimbursement. The first PPS reimbursement period for all hospitals will extend to 6/30/06, after which all PPS updates will be for the 12 month periods beginning 7/1 of each year. The second reimbursement period uses a blend of 50% TEFRA / 50% PPS, and the third and last transition year uses 25% TEFRA / 75% PPS. There is a "stop/loss" adjustment which sets the PPS reimbursement to no less than 70% of the TEFRA amount for this 3 year transition period. The new PPS system uses a federal per diem base amount of $575.95 which is then adjusted for one of 15 DRGs, co-morbidities, age, rural add-on, teaching add-on, outlier reimbursement, wage index, the presence of an emergency department, and ECT treatment. There is also an extra payment which tapers down during the first 21 days of an admission. Psychiatric Hospitals- Outpatient Radiology Registered Dietitian Rehab Hospital-Inpatient Services Rehab Hospital-Outpatient Services Religious Non-Medical Health Care Institutions Reimbursement for these services is based on the OPPS, under Ambulatory Payment Classifications (APCs). The reimbursement rate is at the Medicare Allowable Charge on the Medicare physician Fee Schedule. Reimbursement is at 85% of the Medicare Allowable Charge on the Medicare physician Fee Schedule. Reimbursement is based on the PPS and the case-mix group (CMG) methodology. Reimbursement is based on discharge rates, incorporating facility-level and case-level adjustments. Reimbursement for these services is based on the OPPS, under Ambulatory Payment Classifications (APCs). Reimbursement is on a reasonable cost basis. 8
Rural Health Clinics These facilities are reimbursed 105% of the sum of 80% of the lower of the provider specific interim rate or the per visit payment limit plus 20% of the RHC s billed charges. The 2006 per visit limit is $72.76. Note: Per visit limits do not apply to RHCs owned by rural hospitals with less than 50 beds and are paid on a cost basis. SecureHorizons Direct pays the cumulative amount, less any patient cost-sharing (copayment or coinsurance), which is collected by the RHC at the point of service. The additional 5% is compensation in lieu of a year-end settlement under the SecureHorizons Direct plan. Some services (e.g., flu vaccinations) are not part of the interim rate and are paid separately under RBRVS. SecureHorizons Direct pays these claims at the RBRVS rate, less any patient costsharing (copayment or coinsurance). Billing Instructions: HCFA 1500 use Place of Service Code 72, not 11 UB92 use Bill Type 71 if facility is freestanding; use Bill Type 73 if facility is hospital-based with less than 50 beds. Skilled Nursing Facilities Sole Community Hospital Surgical Dressings The facility can proactively send a copy of its most recent interim rate letter from the Medicare Fiscal Intermediary to SecureHorizons Direct, at the claims address. Or, SecureHorizons Direct will contact the facility for a copy of the most recent interim rate letter upon receipt of a claim. Reimbursement is according to the PPS under related utilization groups (RUG) methodology. As of fiscal year 2002 cost reports, reimbursement is completely derived from the federal rate and includes provisions from the Benefits, Improvements & Protection Act of 2000 (BIPA) and Balanced Budget Refinement Act of 1999 (BBRA). These services are reimbursed according to the PPS, under the DRG methodology. The PPS rate equals the greater of the federal rate or the applicable hospital specific rate (based on cost report data). The Medicare DMEPOS Fee Schedule applies to all surgical dressings except those applied incident to a physician's professional services, those furnished by an HHA and those applied while a patient is being treated in an outpatient hospital department or as an acute care inpatient. Hospital outpatient services are reimbursed under PPS (APCs) HHA's-payment is bundled into PPS (HHRGs). If a physician, certified nurse midwife, physician assistant, nurse practitioner, or clinical nurse specialist applies surgical dressings as part of a professional service that is billed to Medicare, the surgical dressings are considered incident to the professional services of the health care practitioner. 9
Swing Beds VA Hospitals Swing bed reimbursement was transitioned to the SNF PPS effective 7/1/2002. CAH swing beds are exempt from SNF PPS. Federal providers are excluded from participation in the Medicare program. However, Federal Hospitals, like other nonparticipating hospitals may be paid for emergency inpatient and outpatient hospital services. Hospital filed claims: inpatient services are reimbursed at the lower of actual charges or rates published for Federal Hospitals in the Federal Register under Office of Management & Budget - Cost of Hospital & Medical Care & Treatment. Outpatient services are reimbursed at 85% of the total covered charges. 10