Fee Schedules
Reasonable
The actual charge submitted on a claim ( must be reasonable to the provider) The lowest amount is used as the basis for payment ( the allowable charge)
Customary
The average charge of all providers of simular training and experience in a given geographical area.
Usual, Customary, Reasonable
UCR method is used mostly in reference to fee-for-service reimbursement. To arrive at a payment amount for a claim, the carrier compares Usual, Customary, Reasonable charges.
Capitated Rates
Under capitation, the physician provides a full range of contracted services to covered patients for a fixed amount on a periodic basis. The physician assumes the risk that the cost of providing care to the patients may exceed the payment amount.
RBRVS: Overhead
practice costs related to the performing the service.
RBRVS: Work
represents the amount of time,intensity of effort,and medical skill required of the physician.
Contracted Rates with MCO's
Physicians agree to provide services at a discount of their usual fee in return for a pool of existing patients.
Usual
The physician's most frequent charge for a given service.
Medicare's Resource Based Value Scale Payment Shedule (RBRVS)
Under this schedule, a procedure's relative value is the sum total of three elements. Work, Overhead, Malpractice. Payments are determined by multiplying a code's relative value by a constant dollar amount called a conversion factor( Multiplier)
Relataive Value Payment Schedules Method
Use of relative value scales which assign a relative weight to individual services according to the basis of the scale. Services that are more difficult, time consuming, or resource intensive to perform typically have higher relative value than other services.
Medicare conversion factors
conversion factors are determined annually be the CMS in cooperation with Congress. Conversion factor varies according to the type of service provided.
RBRVS: Malpractice
the cost of medical malpractice insurance. Medical malpractice insurance that covers the insured only for those claims made while the policy is in force is called claims-made coverage.
