Rate setting for long term care providers is largely defined by the setting in which the service is performed: hospital or community. The regulatory systems in place are unique for each service setting and payor type.
Psychiatric Hospitals have a unique set of rules which goven rate setting efforts. Medicare reimburses inpatient providers on a Diagnostic Related Grouping (DRG) Prospective Payment System (PPS) for inpatient care and Ambulatory Payment Classification (APCs) for outpatient care. Generally, Medicaid reimburses private psychiatric facilities at FFS rates and public facilities receive cost based rates. Managed Care and Commercial payors usually reimburse providers utilizing FFS, cost based, and/or Pay-for- Performance (PFP) options.
Community Based Providers (Community Mental Health Centers, Psychologists, etc.) follow a separate reimbursement system. Medicare reimburses providers according to the Medicare Physician fee schedule (CPT and HCPCS codes). Medicaid will often mirror the structure of the Medicare Physician Fee Schedule, but often times will adapt the schedule for state-specific service and budget restrictions.
Managed Care and Commercial payors often use the Medicare Physician fee schedule (CPT and HCPCS).
PCG Health™ has provided rate setting services to long term care clients since 1987. Our consultants have extensive experience with behavioral health care rate setting and reimbursement services, including
For more information about PCG Health's Rate Setting Services please contact us at firstname.lastname@example.org or 1-800-210-6113.