Medicare has different payment systems associated with various healthcare settin

Medicare has different payment systems associated with various healthcare settings. In this chapter, you have learned about the hospital-based outpatient setting. This system is not used in the Ambulatory Surgical Center (ASC) setting; rather a modified version of this payment system is used and is called the ASC payment system. Both systems use APCs, but provisions, adjustments, and payment rates are different. Medicare designates which procedures are safe for the ASC setting. In this exercise, we examine a cataract procedure (CPT code 66984) which is one of the most performed procedures for Medicare beneficiaries. This procedure is approved for both the hospital outpatient and ASC settings.

Genie is a 68-year-old female who presents with age-related incipient cataract of the right eye (ICD-10-CM code H25.011). She recently met with her physician about cataract surgery. The physician indicated that she needs extracapsular cataract removal with insertion of an intraocular lens prosthesis (CPT code 66984). Dr. Williams told Genie that she could have the procedure in an outpatient hospital facility or an ambulatory surgical center (ASC).
Let’s examine the reimbursement and cost sharing amounts for each setting.
CPT Code
Outpatient Hospital Facility
Ambulatory Surgical Center
Reimbursement
Cost-Sharing
Reimbursement
Cost-Sharing
66984
$2,021.86
$404.38
$1,012.72
$202.54
Rates as of January 2020
As you can see, the reimbursement and cost sharing amount for the hospital-based outpatient facility is almost twice the amount required for the ASC facility. It is the same procedure, provided by the same physician (Dr. Williams) regardless of setting.
Before you answer the essay questions below, consider the following:
Is the quality of care two times better in the outpatient hospital facility setting?
Are the outcomes of care two times better in the outpatient hospital facility setting?
Are the costs of providing services and care that much lower in the ASC setting?
Are Medicare beneficiaries aware of the disparity of cost-sharing amounts in different surgical settings?
Is it fair to charge different cost-sharing amounts for the same service?
Do you think the difference in cost-sharing would influence your decision for where to have surgery?
Essay:
In at least 300 words, discuss the disparity between the reimbursement and cost-sharing levels of the outpatient hospital facility and ASC. Why is parity and disparity an important topic to discuss? How does it affect the average Medicare beneficiary? What do you think Genie should do? Are there additional questions that Genie should ask Dr. Williams before she makes her decision?