D. Using the "Pseudo Bill" to Find VA Healthcare Cost
3. What are outpatient facility payments, and how can I obtain data on them?
What are outpatient facility payments?Medicare reimburses providers and facilities separately. Outpatient facility payments cover the costs pertaining to outpatient care, such as the use of operating and recovery rooms for ambulatory surgery. The payments are limited to certain types of care and to specific types of facilities. Facilities eligible for Medicare facility payments include the following:
- hospital-based clinics
- emergency rooms
- freestanding ambulatory surgical centers
- federally qualified health centers
- skilled nursing facilities
- rural health clinics
- comprehensive outpatient rehabilitation facilities
- home health agencies
- hospices
The one readily available data source for outpatient facility payments is the Medicare Outpatient Prospective Payment System. In August 2000, Medicare switched from fee-for-service reimbursement to a prospective payment system. Under prospective payment, Medicare assigns each current procedural terminology (CPT) code on the patient record to an Ambulatory Payment Classification (APC) group. Medicare bases the reimbursement rates on studies of the number, type, and cost of services provided. The method for applying APCs and the Medicare payment rates is available on the Medicare web page, http://cms.hhs.gov/regulations/hopps/. Documentation for the HERC Outpatient Average Cost Datasets provides a more detailed discussion.