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Polston M. CMS's aggressive strategy on the provider-based rule raises concerns. Healthc Financ Manage 2016; 70:30-33. [PMID: 29897194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
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2
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DeJohn P. Implementation period for outpatient payment rule cut short by CMS delays. OR Manager 2014; 30:30. [PMID: 24520686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
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3
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van der Put CE, Asscher JJ, Stams GJJM, van der Laan PH, Breuk R, Jongman E, Doreleijers T. Recidivism after treatment in a forensic youth-psychiatric setting: the effect of treatment characteristics. Int J Offender Ther Comp Criminol 2013; 57:1120-1139. [PMID: 22811475 DOI: 10.1177/0306624x12452389] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
The aim of this study was to examine the effect of treatment characteristics on recidivism in a forensic youth-psychiatric outpatient clinic. The treatment offered comprised functional family therapy (FFT), individual cognitive behavioural therapy (CBT), or CBT in combination with parent training. Some of the youth additionally participated in aggression replacement training (ART). FFT and ART were implemented as a trial version, meaning that most therapists had not received formal training yet. Treatment characteristics related to recidivism were length of treatment, type of treatment, number of sessions, and the therapist. The longer the period of treatment and the greater the number of sessions, the higher the recidivism, even after controlling for risk of recidivism based on static risk factors. Juveniles who participated in ART reoffended more often than juveniles who had not participated in such training. Given the fact that FFT and ART were not well-implemented trial versions, it can be concluded that poorly implemented treatment leads to poor outcomes.
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Affiliation(s)
- Claudia E van der Put
- Department of Forensic Child and Youth Care Sciences, Faculty of Social and Behavioral Sciences, University of Amsterdam, P.O. Box 94208, 1090 GE Amsterdam, Netherlands.
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; revisions to payment policies under the physician fee schedule, DME face-to-face encounters, elimination of the requirement for termination of non-random prepayment complex medical review and other revisions to Part B for CY 2013. Final rule with comment period. Fed Regist 2012; 77:68891-9373. [PMID: 23155552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This major final rule with comment period addresses changes to the physician fee schedule, payments for Part B drugs, and other Medicare Part B payment policies to ensure that our payment systems are updated to reflect changes in medical practice and the relative value of services. It also implements provisions of the Affordable Care Act by establishing a face-to-face encounter as a condition of payment for certain durable medical equipment (DME) items. In addition, it implements statutory changes regarding the termination of non-random prepayment review. This final rule with comment period also includes a discussion in the Supplementary Information regarding various programs . (See the Table of Contents for a listing of the specific issues addressed in this final rule with comment period.)
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid programs: Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs; electronic reporting pilot; Inpatient Rehabilitation Facilities Quality Reporting Program; revision to Quality Improvement Organization regulations. Final rule with comment period. Fed Regist 2012; 77:68209-565. [PMID: 23155551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) and the Medicare ambulatory surgical center (ASC) payment system for CY 2013 to implement applicable statutory requirements and changes arising from our continuing experience with these systems. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare services paid under the OPPS and those paid under the ASC payment system. In addition, this final rule with comment period updates and refines the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, the ASC Quality Reporting (ASCQR) Program, and the Inpatient Rehabilitation Facility (IRF) Quality Reporting Program. We are continuing the electronic reporting pilot for the Electronic Health Record (EHR) Incentive Program, and revising the various regulations governing Quality Improvement Organizations (QIOs), including the secure transmittal of electronic medical information, beneficiary complaint resolution and notification processes, and technical changes. The technical changes to the QIO regulations reflect CMS' commitment to the general principles of the President's Executive Order on Regulatory Reform, Executive Order 13563 (January 18, 2011).
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Abstract
A brief review of the Hospital Outpatient Prospective Payment System (HOPPS) is presented highlighting the program's legislative history, outpatient service classifications and payment plan. Specifically, HOPPS measures applicable to imaging practices are discussed. Resources are also provided for further information on the program requirements and the ambulatory payment classifications (APC) system.
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Affiliation(s)
- N Anumula
- Department of Radiology, Weill Cornell Medical College, New York-Presbyterian Hospital, New York, New York 10065, USA
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Hofstra PS, Hart EL. Decoding incident-to and provider-based billing: ensuring payment and avoiding liability. J Med Pract Manage 2012; 27:206-208. [PMID: 22413593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
In this increasingly complex world of Medicare reimbursement, physicians must constantly review their billing practices to ensure compliance with all Medicare requirements. "Incident-to" billing and provider-based billing are two areas that present unique challenges for providers, especially those practicing in hospital-owned practices such as hospital outpatient departments. Both incident-to and provider-based billing limit providers' abilities to bill for and receive reimbursement in those practice settings. The Office of Inspector General's 2012 Work Plan Report identified both incident-to billing and place-of-service errors as two of the many areas for investigation and compliance efforts in 2012. This article focuses on identifying the unique point-of-service challenges presented by physicians practicing in hospital outpatient departments or hospital-owned clinics.
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Al-Amin M. The general NFP hospital model. Am J Econ Sociol 2012; 71:37-53. [PMID: 22324062 DOI: 10.1111/j.1536-7150.2011.00815.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Throughout the past 30 years, there has been a lot of controversy surrounding the proliferation of new forms of health care delivery organizations that challenge and compete with general NFP community hospitals. Traditionally, the health care system in the United States has been dominated by general NFP (NFP) voluntary hospitals. With the number of for-profit general hospitals, physician-owned specialty hospitals, and ambulatory surgical centers increasing, a question arises: “Why is the general NFP community hospital the dominant model?” In order to address this question, this paper reexamines the history of the hospital industry. By understanding how the “general NFP hospital” model emerged and dominated, we attempt to explain the current dominance of general NFP hospitals in the ever changing hospital industry in the United States.
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MESH Headings
- Delivery of Health Care/economics
- Delivery of Health Care/ethnology
- Delivery of Health Care/history
- Delivery of Health Care/legislation & jurisprudence
- Health Care Reform/economics
- Health Care Reform/history
- Health Care Reform/legislation & jurisprudence
- History, 20th Century
- History, 21st Century
- Hospitals, Proprietary/economics
- Hospitals, Proprietary/history
- Hospitals, Proprietary/legislation & jurisprudence
- Hospitals, Special/economics
- Hospitals, Special/history
- Hospitals, Special/legislation & jurisprudence
- Hospitals, Voluntary/economics
- Hospitals, Voluntary/history
- Hospitals, Voluntary/legislation & jurisprudence
- Models, Economic
- Outpatient Clinics, Hospital/economics
- Outpatient Clinics, Hospital/history
- Outpatient Clinics, Hospital/legislation & jurisprudence
- United States/ethnology
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Affiliation(s)
- Mona Al-Amin
- University of Florida, Health Science Center, Gainesville
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare and Medicaid programs: hospital outpatient prospective payment; ambulatory surgical center payment; hospital value-based purchasing program; physician self-referral; and patient notification requirements in provider agreements. Final rule with comment period. Fed Regist 2011; 76:74122-584. [PMID: 22145188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) for CY 2012 to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the OPPS. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the relative payment weights and payment amounts for services furnished in ASCs, specific HCPCS codes to which these changes apply, and other ratesetting information for the CY 2012 ASC payment system. We are revising the requirements for the Hospital Outpatient Quality Reporting (OQR) Program, adding new requirements for ASC Quality Reporting System, and making additional changes to provisions of the Hospital Inpatient Value-Based Purchasing (VBP) Program. We also are allowing eligible hospitals and CAHs participating in the Medicare Electronic Health Record (EHR) Incentive Program to meet the clinical quality measure reporting requirement of the EHR Incentive Program for payment year 2012 by participating in the 2012 Medicare EHR Incentive Program Electronic Reporting Pilot. Finally, we are making changes to the rules governing the whole hospital and rural provider exceptions to the physician self-referral prohibition for expansion of facility capacity and changes to provider agreement regulations on patient notification requirements.
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Daly R. Breaking the rules. Fiscal benefits of less red tape questioned. Mod Healthc 2011; 41:8-9. [PMID: 22111138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
MESH Headings
- Centers for Medicare and Medicaid Services, U.S./economics
- Centers for Medicare and Medicaid Services, U.S./legislation & jurisprudence
- Centers for Medicare and Medicaid Services, U.S./standards
- Cost Control/legislation & jurisprudence
- Cost Control/methods
- Efficiency, Organizational
- Financial Management, Hospital/economics
- Financial Management, Hospital/legislation & jurisprudence
- Financial Management, Hospital/standards
- Government Regulation
- Humans
- Outpatient Clinics, Hospital/economics
- Outpatient Clinics, Hospital/legislation & jurisprudence
- Outpatient Clinics, Hospital/standards
- Personnel, Hospital/economics
- Personnel, Hospital/legislation & jurisprudence
- Personnel, Hospital/standards
- Surgicenters/economics
- Surgicenters/legislation & jurisprudence
- Surgicenters/standards
- United States
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Barr P. Hostile reception. Value-based purchasing changes get poor reviews. Mod Healthc 2011; 41:10-11. [PMID: 21850895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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12
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Court sides with clinic in legal fight with malpractice insurer. Minn Med 2011; 94:19. [PMID: 21736201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
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Manow ML, Paulsen N, Rybczynski M, Mir T, Bernhardt AMJ, Treede H, Ohm G, Fuisting B, Rehder U, Meier F, Vogler M, Meinertz T, Overlack K, von Kodolitsch Y. [Analysis of costs and profits of ambulatory care of Marfan patients after initiation of a novel German legal directive (116 b SGB V)]. ACTA ACUST UNITED AC 2010; 105:529-37. [PMID: 20824410 DOI: 10.1007/s00063-010-1090-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2010] [Accepted: 06/16/2010] [Indexed: 11/25/2022]
Abstract
BACKGROUND The Marfan syndrome is a typical rare disease with multiorgan involvement and the need for specialized interdisciplinary medical care. A novel German legal directive according to section sign 116 b of the Social Statutes Book V (116 b SGB V) improves options for reimbursement and thus encourages specialized hospitals to provide ambulatory care for rare diseases such as Marfan syndrome. The authors provide the first economic analysis of section sign 116 b in a German Marfan center. METHODS The costs were assessed in 184 cases with Marfan syndrome receiving medical care in the Hamburg Marfan Clinic. The authors assessed the financial profit both according to payments received from invoices established according to the 116 b directive [reimbursement (116b)] and from calculations according to section sign 117 SGB V [reimbursement (117)]. RESULTS A total of 117 patients traveled to the Marfan clinic (64%) < 50 km, 27 patients (15%) between >or= 50 and <or= 100 km, and 40 patients (22%) > 100 km. The total costs for ambulatory care were 71,606.28 Euro. The reimbursement (116b) was 55,549.87 Euro and the reimbursement (117) was 11,776.00 Euro. CONCLUSION Many patients accept long distances of traveling to receive specialized ambulatory medical care. However, for optimal patient management specialized centers need to cooperate intensively with local health care providers. The novel legal directive according to section sign 116 b has significantly improved reimbursement for Marfan centers and allows for improving the quality of medical care.
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Affiliation(s)
- Marie-Luise Manow
- Universitäres Herzzentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
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14
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Lubell J. On-site shortsighted. Critical-access hospitals at odds with supervision plan. Mod Healthc 2010; 40:10. [PMID: 20879119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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15
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Blesch G. Big win for the government. Settlement gives inspector general 'some teeth'. Mod Healthc 2010; 40:14. [PMID: 20669382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Crosswhite CL. CMS modifies Medicare policies regarding supervision requirements for hospital outpatient services. J Med Pract Manage 2010; 26:47-48. [PMID: 20839513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Lubell J. Bundle of problems. Hospitals seek to keep '72-hour rule' intact. Mod Healthc 2010; 40:8-9. [PMID: 20578317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program: changes to the hospital outpatient prospective payment system and CY 2010 payment rates; changes to the ambulatory surgical center payment system and CY 2010 payment rates. Final rule with comment period. Fed Regist 2009; 74:60315-983. [PMID: 20166279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This final rule with comment period revises the Medicare hospital outpatient prospective payment system (OPPS) to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we describe the changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2010. In addition, this final rule with comment period updates the revised Medicare ambulatory surgical center (ASC) payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system. In this final rule with comment period, we set forth the applicable relative payment weights and amounts for services furnished in ASCs, specific HCPCS codes to which these changes will apply, and other pertinent ratesetting information for the CY 2010 ASC payment system. These changes are applicable to services furnished on or after January 1, 2010.
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicaid program: rescission of School-Based Administration/Transportation final rule, Outpatient Hospital Services final rule, and partial rescission of Case Management Interim final rule. Final rule. Fed Regist 2009; 74:31183-96. [PMID: 19588575] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
This rule finalizes our proposal to rescind the December 28, 2007 final rule entitled, "Elimination of Reimbursement under Medicaid for School Administration Expenditures and Costs Related to Transportation of School-Age Children Between Home and School;" the November 7, 2008 final rule entitled, "Clarification of Outpatient Hospital Facility (Including Outpatient Hospital Clinic) Services Definition;" and certain provisions of the December 4, 2007 interim final rule entitled, "Optional State Plan Case Management Services." These regulations have been the subject of Congressional moratoria and have not yet been implemented (or, with respect to the case management interim final rule, have only been partially implemented) by CMS. In light of concerns raised about the adverse effects that could result from these regulations, in particular, the potential restrictions on services available to beneficiaries and the lack of clear evidence demonstrating that the approaches taken in the regulations are warranted, CMS is rescinding the two final rules in full, and partially rescinding the interim final rule. Rescinding these provisions will permit further opportunity to determine the best approach to further the objectives of the Medicaid program in providing necessary health benefits coverage to needy individuals.
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicaid program; clarification of outpatient hospital facility (including outpatient hospital clinic) services definition. Final rule. Fed Regist 2008; 73:66187-98. [PMID: 19112700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
Outpatient hospital services are a mandatory part of the standard Medicaid benefit package. This final rule aligns the Medicaid definition of outpatient hospital services more closely to the Medicare definition in order to: Improve the functionality of the applicable upper payment limits (which are based on a comparison to Medicare payments for the same services), provide more transparency in determining available hospital coverage in any State, and generally clarify the scope of services for which Federal financial participation (FFP) is available under the outpatient hospital services benefit category.
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Walter U. [Accounting in ambulatory surgery in the hospital of patients with private health insurance]. Chirurg 2008; Suppl:136-139. [PMID: 18985894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Affiliation(s)
- U Walter
- Fachanwältin für Medizinrecht, Kanzlei Ulsenheimer und Partner, München.
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Affiliation(s)
- C Sicot
- Groupe MACSF, Le Sou-Médical, 10, cours du triangle de l'Arche, TSA 40100, 92919, La Défense cedex, France.
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de Ruiter C, Trestman RL. Prevalence and treatment of personality disorders in Dutch forensic mental health services. J Am Acad Psychiatry Law 2007; 35:92-7. [PMID: 17389350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
Offenders with serious personality disorders challenge forensic systems throughout the world. In this article, the authors describe the legal system that shapes the forensic treatment of personality-disordered offenders in the Dutch psychiatric and correctional systems. The evolution of laws and regulations are addressed, as is the bifurcation of treatment between forensic hospitals and correctional settings. Prevalence data of personality disorders in the Dutch systems are presented, and comparisons between the Dutch and American systems are delineated. Current treatment modalities are described. Research initiatives and future directions for the system are presented.
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Affiliation(s)
- Corine de Ruiter
- Department of Psychology, Maastricht University, P.O. Box 616, 6200 MD Maastricht, The Netherlands.
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; hospital outpatient prospective payment system and CY 2007 payment rates; CY 2007 update to the ambulatory surgical center covered procedures list; Medicare administrative contractors; and reporting hospital quality data for FY 2008 inpatient prospective payment system annual payment update program--HCAHPS survey, SCIP, and mortality. Final rule with comment period and final rule. Fed Regist 2006; 71:67959-8401. [PMID: 17133695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system, and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 and the Deficit Reduction Act (DRA) of 2005. In this final rule with comment period, we describe changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2007. In addition, this final rule with comment period implements future CY 2009 required reporting on quality measures for hospital outpatient services paid under the prospective payment system. This final rule with comment period revises the current list of procedures that are covered when furnished in a Medicare-approved ambulatory surgical center (ASC), which are applicable to services furnished on or after January 1, 2007. This final rule with comment period revises the emergency medical screening requirements for critical access hospitals (CAHs). This final rule with comment period supports implementation of a restructuring of the contracting entities responsibilities and functions that support the adjudication of Medicare fee-for-service (FFS) claims. This restructuring is directed by section 1874A of the Act, as added by section 911 of the MMA. The prior separate Medicare intermediary and Medicare carrier contracting authorities under Title XVIII of the Act have been replaced with the Medicare Administrative Contractor (MAC) authority. This final rule continues to implement the requirements of the DRA that require that we expand the "starter set" of 10 quality measures that we used in FY 2005 and FY 2006 for the hospital inpatient prospective payment system (IPPS) Reporting Hospital Quality Data for the Annual Payment Update (RHQDAPU) program. We began to adopt expanded measures effective for payments beginning in FY 2007. In this rule, we are finalizing additional quality measures for the expanded set of measures for FY 2008 payment purposes. These measures include the HCAHPS survey, as well as Surgical Care Improvement Project (SCIP, formerly Surgical Infection Prevention (SIP)), and Mortality quality measures.
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Becker C. Patients push for price data. Lawsuits, regulations could cause consumers nationwide to start seeking more transparency from hospitals on outpatient fees. Mod Healthc 2006; 36:6-7, 16, 1. [PMID: 17153781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
Abstract
Lawsuits over hospital outpatient fees, including a case at Virginia Mason Medical Center, could prompt consumers nationwide to seek more information about their bills. The issue highlights the turf battle between physician- or corporate-owned clinics and competing hospital facilities, and how they're marketed. "We absolutely agree that patients need full information", says Virginia Mason's Sarah Patterson, left.
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DoBias M. CMS extends deadline, but some say '09 still too soon for quality measures. Mod Healthc 2006; 36:8-9. [PMID: 17128944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/12/2023]
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Jarrett AT. Effect of the Medicare Prescription Drug Improvement and Modernization Act on the bottom line. Am J Health Syst Pharm 2006; 63:S10-3. [PMID: 17057054 DOI: 10.2146/ajhp060462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE An historical perspective on the impact of the Medicare Prescription Drug Improvement and Modernization Act (MMA) on pharmaceutical reimbursement, and the financial bottom line at health systems and various strategies to use in the inpatient and outpatient setting to improve the bottom line are described. SUMMARY Implementation of MMA has affected the entire healthcare continuum by reducing pharmaceutical reimbursement rates and health system revenues and increasing prescription drug copayments, emergency department visits, and hospital admissions. Physician-owned clinics are less profitable than in the past because of MMA, which may prompt clinic closures and shift the patient care burden to clinics at public hospitals. Negotiating carve-outs for costly drugs and evaluating the feasibility of obtaining outlier payments can improve the bottom line in the hospital inpatient setting. Ensuring that billing codes are accurate and verifying that reimbursement was received can help minimize the impact of MMA on the financial bottom line in the outpatient setting. Negotiating favorable purchasing contracts and ensuring that drugs are used appropriately by following evidence-based guidelines can improve the financial bottom line in both the inpatient and outpatient settings. CONCLUSION Strategies to decrease drug acquisition costs and increase reimbursement rates can help minimize the adverse impact of MMA on the financial bottom line at health systems.
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Affiliation(s)
- Anne T Jarrett
- Wake Forest University Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Jarrett AT. Understanding basic concepts and strategies for obtaining pharmaceutical reimbursement. Am J Health Syst Pharm 2006; 63:S7-9. [PMID: 17057059 DOI: 10.2146/ajhp060461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
PURPOSE The rules that govern pharmaceutical reimbursement and strategies for obtaining reimbursement for hospital inpatients and outpatients and patients treated at physician-owned clinics are discussed. SUMMARY The use of certain claim forms and provision of information about the patient location, drug, Healthcare Common Procedure Coding System (HCPCS) code, status indicator, billing unit, revenue code, and International Classification of Diseases, 9th Revision (ICD-9) code are required to obtain reimbursement for pharmaceuticals from the Centers for Medicare & Medicaid Services. Requirements for hospital inpatients and outpatients differ. Claims for patients treated at physician-owned clinics are handled differently from claims for those treated at hospital outpatient clinics, but pharmaceutical reimbursement rates are the same in the two settings. CONCLUSION Frequent changes in the rules for obtaining pharmaceutical reimbursement present a challenge. A knowledge of the rules and requirements for different patient treatment settings is needed to obtain reimbursement.
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Affiliation(s)
- Anne T Jarrett
- Wake Forest University Medical Center, Medical Center Boulevard, Winston-Salem, NC 27157, USA.
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Steinbrück R. [Medical care center. Chances and risk for hospital medical director]. Chirurg 2006; Suppl:72-6. [PMID: 16921612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
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Luxenburger B. [The growing endangerment of specialists in private practice--opening up access to hospital outpatient clinics from a legal point of view]. Z Arztl Fortbild Qualitatssich 2006; 100:69-73. [PMID: 16524234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/07/2023]
Abstract
There are two new rules of the German Health System Modernisation Act (GMG) affecting the activity of specialists in private practice: the authorization of a hospital according to Sect. 116 a (SGB V; Title Five of the Social Code) subsidiary to the registration of a SHI physicians and the authorization of a hospital-based physician. Negative effects on office-based physician in private practice will only occur if, for example, an ambulatory healthcare centre (MVZ) is being established by the hospital owner. Currently, Sect. 116 b SGB V also does not have any negative impact on office-based specialists. The benefits catalogue according to Sect. 116 b Para 3 SGB V has so far been narrowly defined. And, in the face of the diverging interests within the Joint Federal Committee Health Insurances/NationalAssociation of Statutory Health Insurance Physicians and Health Reform Consensus Act (GKG)--a noticeable broadening of this catalogue is not to be expected. Also, such a broadening of the scope of this catalogue will be counteracted by the fact that no legal right exists to the conclusion of a contract with the health insurance companies and that the health insurers will actually have to additionally reimburse for medical services according to the catalogue of Sect. 116b Para 3 SGB V beyond the total reimbursement budget.
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Taylor M. First of many? Vaccine probe may extend beyond Connecticut. Mod Healthc 2005; 35:20. [PMID: 15765841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; changes to the hospital outpatient prospective payment system and calendar year 2005 payment rates. Final rule with comment period. Fed Regist 2004; 69:65681-6233. [PMID: 15551492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
This final rule with comment period revises the Medicare hospital outpatient prospective payment system to implement applicable statutory requirements and changes arising from our continuing experience with this system and to implement certain related provisions of the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003. In addition, the final rule with comment period describes final changes to the amounts and factors used to determine the payment rates for Medicare hospital outpatient services paid under the prospective payment system. These changes are applicable to services furnished on or after January 1, 2005. In this final rule with comment period, we are responding to public comments received on the January 6, 2004 interim final rule with comment period relating to MMA provisions that were effective January 1, 2004, and finalizing those policies. Further, we are responding to public comments received on the November 7, 2003 final rule with comment period pertaining to the ambulatory payment classification assignment of Healthcare Common Procedure Coding System (HCPCS) codes identified in Addendum B of that rule with the new interim (NI) comment indicators (formerly referred to as condition codes).
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Tieman J. CMS rejiggers outlier rules. Mod Healthc 2004; 34:10. [PMID: 15560630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
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Bailes JS, Coleman T. The new Medicare bill: far-reaching effects on cancer treatment. Clin Adv Hematol Oncol 2004; 2:292-4. [PMID: 16163195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/04/2023]
Abstract
Recent legislation has dramatically changed the Medicare payment methods for drugs and drug administration services. A large net reduction in total payments will take effect in 2005 and is likely to have significant adverse effects on the delivery of care to cancer patients.
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Wohlgemuth WA, Mayer J, Nagel E, Bohndorf K. Aktuelle gesetzgeberische Initiativen zur Integrierten Versorgung - Auswirkungen auf die ambulante Versorgung am Krankenhaus. ROFO-FORTSCHR RONTG 2004; 176:484-90. [PMID: 15088171 DOI: 10.1055/s-2004-813024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The strict separation of the out-patient and hospital-based health care delivery sectors in Germany leads to deficits in effectiveness and efficiency. Newly introduced legal initiatives to overcome this separation, namely "Ambulantes Operieren" (section 115 b SGB V), "Ambulante Behandlung durch Krankenhäuser" and Disease Management Programs (sections 116a-b SGB V) are described in detail in this article. Their impact on hospital-based health provision for out-patients is discussed. The aim of a better integration of different sectors with a better quality and a more efficient use of resources seems to be the target of these initiatives.
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Affiliation(s)
- W A Wohlgemuth
- Institut für Medizinmanagement und Gesundheitswissenschaften, Universität Bayreuth.
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The new EMTALA regulations--introduction. J Health Law 2004; 37:1-6. [PMID: 15191233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
This Introduction provides a broad overview of the new Emergency Medical Treatment and Labor Act (EMTALA) regulations and the changes they effected. The three Articles that follow discuss various aspects of the regulations in much greater detail. Health Lawyers Teleconference: EMTALA Update provides a commentary on the regulations from the perspective of representatives of the Centers for Medicare & Medicaid Services and the Department of Health and Human Services, followed by a critique of the regulations from a practitioner's standpoint. EMTALA: Dedicating an Emergency Department Near You analyzes the provisions of the regulations in detail and discusses their implications for hospitals and their counsel. Finally, The New EMTALA Regulations and the On-Call Physician Shortage: In Defense of the Regulations analyzes the on-call provisions of the regulations in light of the current shortage of on-call physicians.
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Rice B. Look before you leap. Med Econ 2003; 80:66, 69, 73. [PMID: 14712584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
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Wienke A. [Legal implications of the interlocking of ambulatory and stationary care]. Z Arztl Fortbild Qualitatssich 2003; 97:603-6. [PMID: 14710652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
In Germany, ambulatory and stationary care are separated at both a legal and an organisational level. For some time though there have been efforts to make the border between these two sectors of care more permeable. However, the measures that have been implemented in order to achieve this goal such as the forms of integrated care in accordance with sections 140 a et seqq. of the Fifth Book of Social Code (SGB V) have yet failed to meet with the intended success, which is due to a lack of co-operation between the two sectors. One of the reasons is economic: on the one hand, the interlocking of the two sectors of care is supposed to bring about increased and more efficient co-operation between providers of care, on the other hand, though, these terms may easily be reduced to a single outcome, that is being "cheaper". The other is that medical professionals suffer from a legally founded fear of contact resulting from the difficult legal separation of areas of responsibility and liability between ambulatory and stationary care. There are considerable differences between the two sectors in respect of both organisational and clinical issues so that the respective liability parameters are of a different nature and different legal relevance.
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Welschehold M, Jordan A, Berger W. [Development and initial results of AmBADO. Ambulatory basic documentation in outpatient psychiatric clinics of Bavarian district hospitals]. Psychiatr Prax 2003; 30 Suppl 2:S143-50. [PMID: 14509062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/27/2023]
Abstract
As of 1.1.2002 a new documentation system (AmBADO) has been introduced to the out-patient departments of all Bavarian psychiatric clinics. With the use of this new system, practitioners are for the first time allowed to collect data concerning structure, process, and outcome parameters in this field of care. A pilot study was conducted in 2000 before statewide introduction; this occurred at the "Atriumhaus", a psychiatric crisis- and treatment centre in Munich. Experiences gathered in this study will be presented and examples for possible benefits of using the new system will be discussed.
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Affiliation(s)
- Michael Welschehold
- Psychiatrisches Krisen- und Behandlungszentrum Atriumhaus, Bavariastrasse 11, 80336 München.
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Affiliation(s)
- A Spengler
- Niedersäschisches Landeskrankenhaus Wunstorf, Südstr. 25, 31515 Wunstorf.
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Weingarten JP. The regulation of outpatient services: an analysis of the interaction between HCFA and Medicare providers. J Health Hum Serv Adm 2002; 24:27-53. [PMID: 12134561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
Abstract
The Federal Register is used as a historical record documenting the interaction between the Health Care Financing Administration (HCFA) and health care providers in the regulation of outpatient surgery services to Medicare patients. A content analysis of the Federal Register reveals that HCFA is more likely to accommodate requests for clarification, for shifting services among payment levels, and for adding or deleting services from coverage than for altering payment methods. These findings can be used by health care providers to develop strategies for coping with the expansion of prospective payment to all outpatient services.
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Proposed changes to EMTALA lack direction. Prior authorization, off-site locations addressed. Hosp Case Manag 2002; 10:123-5. [PMID: 12192826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
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Manson LA, Baptist AJ. Assessing the cost-effectiveness of provider-based status. Healthc Financ Manage 2002; 56:52-8. [PMID: 12222012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/26/2023]
Abstract
Clinics with provider-based status often receive greater Medicare payments. Coinsurance costs are higher with provider-based status. Operational changes may be necessary to satisfy provider-based status requirements. Hospitals should identify potential payment increases and associated costs to determine whether provider-based status is cost-effective. If provider-based status is desirable, hospitals should make sure the government's guidelines and regulatory deadlines are met.
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Frank G. CMS clarifies application of EMTALA to off-site outpatient departments and to hospital campuses. J Emerg Nurs 2002; 28:57-9. [PMID: 11830738 DOI: 10.1067/men.2002.121607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Gloria Frank
- EMTALA for the Centers for Medicare & Medicaid Services, USA.
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Ferman JH. The controversial new OPPS rule. Healthc Exec 2002; 17:58-9. [PMID: 11822249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- John H Ferman
- Health Policy Alternatives, Inc., 400 N. Capitol St. NW, Ste. 799, Washington, DC 20001-1536, USA
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Lovern E. Passed through, but not over. Hospitals won victory of sorts in delaying 2002 outpatient payment rule. Mod Healthc 2001; 31:26. [PMID: 11808384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Lovern E. Delays, delays, even more delays. Mod Healthc 2001; 31:5, 16. [PMID: 11828978] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program--prospective payment system for hospital outpatient services: criteria for establishing additional pass-through categories for medical devices. Interim final rule with comment period. Fed Regist 2001; 66:55849-57. [PMID: 11760764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/17/2023]
Abstract
This interim final rule with comment period sets forth the criteria the Secretary will use to establish new categories of medical devices eligible for transitional pass-through payments under Medicare's hospital outpatient prospective payment system.
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49
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Centers for Medicare & Medicaid Services (CMS), HHS. Medicare program; announcement of the calendar year 2002 conversion factor for the hospital outpatient prospective payment system and a pro rata reduction on transitional pass-through payments. Final rule. Fed Regist 2001; 66:55857-66. [PMID: 11760765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
This final rule announces the Medicare hospital outpatient prospective payment system conversion factor for calendar year (CY) 2002. In addition, it describes the Secretary's estimate of the total amount of transitional pass-through payments for CY 2002 and the implementation of a uniform reduction in each of the pass-through payments for that year.
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50
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Affiliation(s)
- L Berlin
- Department of Radiology, Rush North Shore Medical Center, 9600 Gross Point Rd., Skokie, IL 60076, USA
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