Week 2 – Fee Schedules
Fee Schedules are important in healthcare and are not just for Medicare. Commercial Payors base their contracted rates (rates that they negotiate w/ hospitals) off of the Fee Schedules. There are two MPFS and OPPS. For this Assignment you will write a paper and corresponding presentation giving an overview of the two systems as well as building example model of MPFS. It is your choice on which disease state and treatment to build models. I am only looking for single treatments here in your models. I do not care how you build your model but at the end of this document there are some examples. It is up to you to decide how to build it. There are many examples out there. But, you must do the research. This is complicated. Do not reach out to me if you have not done some research. If you feel that you have hit a brick-wall; It is ok to reach out to me, but if I feel that you have not tried, you will receive a zero for the assignment. Overview: Medicare, Medicare Advantage, Part D, Medicare Supplement, Medicaid, Affordable Care Act Explained https://www.youtube.com/watch?v=gyTf-yzavvY • This is a good overview video that might include a lot of what you learned in HAP 301 Watch: How Are Doctors Paid? Learn the Incentives in Physician Compensation https://www.youtube.com/watch?v=WVXiphqmyX0 Watch: How Doctor Relative Value Units (RVUs) Work – Secret to How Doctors Get Paid https://www.youtube.com/watch?v=mFlafz-wTro Watch: Doctor Pay: RVUs Determine Income https://www.youtube.com/watch?v=eumRcvHkwAI Now for the modeling Note: there is also a look-up tool online if you don’t want to work w/ the addenda. But there is more information in the addenda and working w/ the full datasets will give you a more complete picture. The choice is yours. https://www.cms.gov/medicare/physician-feeschedule/search?Y=0&T=4&HT=0&CT=3&H1=33503&M=5 For the MPFS https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched 1 https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulationnotices/cms-1770-f Download the zip file w/ the addenda https://www.cms.gov/files/zip/cy-2023-pfs-final-rule-addenda.zip Download the zip file w/ the addenda https://www.cms.gov/license/ama?file=/files/zip/2023-nfrm-opps-addenda.zip • • • • • Addenda A will give you drug pricing (line up a disease state w/ a drug treatment), include the costs and is organized by APC Addenda B will give you drug pricing based on HCPCS code. This is more relevant. It is much easier to line up diagnosis code (ICD-10) w/ a treatment code. Don’t worry about the other addenda In your model be sure to include definitions of each field, the purpose is to show that you know the fields that CMS is using to publish the data For the MPFS model be sure to include a summary of GPCI and include that in your workup. You should use Excel and use the built-in VLOOKUP to reference the GPCI. This means that you will specify where your practice is, e.g. STATE to get the relative weights. o Be sure to identify all fields, e.g. what does PE GPCI mean Examples: MPFS Coronary Bypass Surgery CPT Code = 33503 RVUs = 22.51 2 OPPS Now you are going to hate me….since Medicare is running out of money, they have also introduced a conversion factor to further bring payments down. You will need to include this in your modeling and you need to explain all of this in your paper and presentation. It is important that you have a full grasp of every element. The good news is that once you learn it, you don’t have re-learn it. Just pay attention to the changes that come out every year, and understand their significance. I will be looking for these points in the last part of your paper and presentation. 3 4
| Excellent | Good | Fair | Poor | ||
| Main Posting | 45 (45%) – 50 (50%)
Answers all parts of the discussion question(s) expectations with reflective critical analysis and synthesis of knowledge gained from the course readings for the module and current credible sources.
Supported by at least three current, credible sources.
Written clearly and concisely with no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
40 (40%) – 44 (44%)
Responds to the discussion question(s) and is reflective with critical analysis and synthesis of knowledge gained from the course readings for the module.
At least 75% of post has exceptional depth and breadth.
Supported by at least three credible sources.
Written clearly and concisely with one or no grammatical or spelling errors and fully adheres to current APA manual writing rules and style. |
35 (35%) – 39 (39%)
Responds to some of the discussion question(s).
One or two criteria are not addressed or are superficially addressed.
Is somewhat lacking reflection and critical analysis and synthesis.
Somewhat represents knowledge gained from the course readings for the module.
Post is cited with two credible sources.
Written somewhat concisely; may contain more than two spelling or grammatical errors.
Contains some APA formatting errors. |
0 (0%) – 34 (34%)
Does not respond to the discussion question(s) adequately.
Lacks depth or superficially addresses criteria.
Lacks reflection and critical analysis and synthesis.
Does not represent knowledge gained from the course readings for the module.
Contains only one or no credible sources.
Not written clearly or concisely.
Contains more than two spelling or grammatical errors.
Does not adhere to current APA manual writing rules and style. |
|
| Main Post: Timeliness | 10 (10%) – 10 (10%)
Posts main post by day 3. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not post by day 3. |
|
| First Response | 17 (17%) – 18 (18%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
15 (15%) – 16 (16%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
13 (13%) – 14 (14%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 12 (12%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Second Response | 16 (16%) – 17 (17%)
Response exhibits synthesis, critical thinking, and application to practice settings.
Responds fully to questions posed by faculty.
Provides clear, concise opinions and ideas that are supported by at least two scholarly sources.
Demonstrates synthesis and understanding of learning objectives.
Communication is professional and respectful to colleagues.
Responses to faculty questions are fully answered, if posed.
Response is effectively written in standard, edited English. |
14 (14%) – 15 (15%)
Response exhibits critical thinking and application to practice settings.
Communication is professional and respectful to colleagues.
Responses to faculty questions are answered, if posed.
Provides clear, concise opinions and ideas that are supported by two or more credible sources.
Response is effectively written in standard, edited English. |
12 (12%) – 13 (13%)
Response is on topic and may have some depth.
Responses posted in the discussion may lack effective professional communication.
Responses to faculty questions are somewhat answered, if posed.
Response may lack clear, concise opinions and ideas, and a few or no credible sources are cited. |
0 (0%) – 11 (11%)
Response may not be on topic and lacks depth.
Responses posted in the discussion lack effective professional communication.
Responses to faculty questions are missing.
No credible sources are cited. |
|
| Participation | 5 (5%) – 5 (5%)
Meets requirements for participation by posting on three different days. |
0 (0%) – 0 (0%) | 0 (0%) – 0 (0%) | 0 (0%) – 0 (0%)
Does not meet requirements for participation by posting on 3 different days. |
|
| Total Points: 100 | |||||