The Clinician???s Role in Medicare Prospective Payment

Abstract

Pamela Teenier, RN, BSN, MBA, CHCE, COS-C, is Director of Medicare Operations, Gentiva Health Services, Corpus Christi, TX. Correspondence: [email protected]. Editor’s Note:This is the fourth in a series of articles discussing focus areas clinicians need to know when providing care for patients in the Medicare Prospective Payment System (PPS). The first article was an overview of the basic elements of Medicare’s Prospective Payment System, PPS (August 2004). Next, the focus was evaluating case mix weight to determine if assessments were completed appropriately (November 2004). The third addressed utilization management, exploring how to monitor visits per episode to contain costs (April 2005). Case mix weight evaluation and utilization monitoring begin at the start of care and work throughout the episode. In this you are at the end of the episode when adjustments are processed. Five events can occur that will create an adjustment to the established episode reimbursement amount (August 2004). This article discusses ways to evaluate adjustments that are occurring and provides suggestions for reducing the amount of revenue lost.