Medicare Prospective Payment Systems
Prospective Payment System (PPS)
- Creates an incentive for hospitals to operate in a more cost-effective manner
- Fee-for-Service: Payments to providers are cost-based and pre-determined fixed amounts (fee schedule) for:
Inpatient
Outpatient
Skilled Nursing
Home Care
Rehab
Long-term Care
Inpatient Psych
Critical Access Hospitals
- Reimbursed by Medicare for both inpatient and outpatient services on the basis of reasonable costs
- Medicare pays the costs actually incurred less any portion found to be unnecessary in the efficient delivery of needed health services.
- Reasonable care consists of determining which costs are allowable; classifying those costs into various hospital cost centers , and then approtioning those costs between Medicare and non-Medicare patients.
Sole Community Hospitals
The sole community provider hsopital program:
- Counties provide matching funds that enable the state to match federal funds for the program.
- This helps our rural providers and UNMH receive equitable funding under the annual Medicare upper payment limit determination.
Upper Payment Limit determination
- The last couple of years some counties, in spite of the fact they have imposed all available taxing authroity for such purposes, have had a difficult time fully matching the available federal funds for their sole community provier hospitals.
Medicare Fee-for-service vs. Medicare Advantage
Medicare Fee-for Services: traditional coverage in which Medicare makes payments directly to providers.
Medicare Advantage: Managed care version in which enrollee contracts with plans for Medicare coverage.
Medicare Advantage Plans
Designed to:
- Offer Medicare beneficiaries options similar to those available in the private sector to people with employment-based health insurance.
- Expand access to managed care options for Medicare beneficiaries in rural and other areas.
Current Medicare Advantage Plans:
Salud
Presbyterian Health Systems
Lovelace Health Plan
Blue Cross Blue Shield
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Comparison of Prospective Payment Systems
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NM Hospitals' State Economic Impact
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NM Uncompensated Care Report
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NM Hospital Under-Reimbursement (HURT)
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NM Medicare Margins
