Get 2016 PPS Reform Worksheet - Healthcare Provider Solutions

A Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services).

A diagnosis-related group (DRG) is a case-mix complexity system implemented to categorize patients with similar clinical diagnoses in order to better control hospital costs and determine payor reimbursement rates.

A partial episode payment (PEP) adjustment is made when a patient elects to transfer to another HHA or is discharged and readmitted to the same HHA during the 60-day episode.

First, the fun part: Medicare payments. IPPS sets the payment rates for inpatient care (covered by Medicare Part A) while OPPS sets the payment rates for outpatient care (covered by Part B).

Medicare's Prospective Payment System The PPS is the DRG. The DRG is based on the patient diagnosis. The DRG payment is per stay. The amount of reimbursement is based on the relative weight of the DRG.

Purpose Medicare DRG (CMS-DRG & MS-DRG) Refined DRGs (R-DRG) All Patient DRGs (AP-DRG) Severity DRGs (S-DRG) All Patient, Severity-Adjusted DRGs (APS-DRG) All Patient Refined DRGs (APR-DRG) International-Refined DRGs (IR-DRG)

A Prospective Payment System (PPS) is a method of reimbursement in which Medicare payment is made based on a predetermined, fixed amount. The payment amount for a particular service is derived based on the classification system of that service (for example, diagnosis-related groups for inpatient hospital services).

This payment system is referred to as the inpatient prospective payment system (IPPS). Under the IPPS, each case is categorized into a diagnosis-related group (DRG). Each DRG has a payment weight assigned to it, based on the average resources used to treat Medicare patients in that DRG.