Medicare
A federal program available to people age 65 and over as well as to certain persons under age 65 with disabilities or with end-stage renal disease. Medicare reimburses healthcare providers using a prospective payment system for inpatient services. Under this system, there are predetermined, fixed amounts that the federal government agrees to pay based on a patient's diagnosis and treatment. Medicare outpatient services are also reimbursed using a prospective payment system.
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Medicare Margins
- Medicare payment shortfalls have resulted in a steady reduction in aggregate Medicare margins. New Mexico hospitals' Medicare margins were at a negative 10.9 percent in 2006, and the projected trend continues to move in a downward spiral. Without considering the Medicare payment windfall for specialty hospitals, a payment policy that Congress clearly needs to address, nearly all of New Mexico's Prospective Payment System (PPS) hospitals have negative Medicare operating margins.
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Medicare 101
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Recovery Audit Contractor (RAC) Program
- The Medicare Modernization Act of 2003 established the Medicare Recovery Audit Contractor (RAC) program as a demonstration program to identify improper Medicare payments - both overpayments and underpayments. RACs are paid on a contingency fee basis, receiving a percentage of the improper overpayments and underpayments they collect from providers.
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Payment Systems (Rules)
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AHA Medicare Issues
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New Mexico Hospitals' Under Reimbursement Trends (HURT)
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Medicare Search Engines
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FAQs DSH Reporting and Audit Requirements - January 2010
