Fee Schedules are important in healthcare and are not just for Medicare. Commerc

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 models of each (MPFS and OPPS). It is your choice on which disease state and treatment to build models (you must build two examples for MPFS and two examples for OPPS). 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

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

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

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-fee-schedule/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
https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulation-notices/cms-1770-f
Download the zip file w/ the addenda
https://www.cms.gov/files/zip/cy-2023-pfs-final-rule-addenda.zip
For the OPPS:
https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospital-outpatient-regulations-and-notices/cms-1772-fc
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. Be sure to identify all fields, e.g. what does PE GPCI mean Examples:
MPFS
Coronary Bypass Surgery
CPT Code = 33503
RVUs = 22.51
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.