Del-Bene's bill would increase the NTAP payment amount from 50 percent to 80 percent to align with the Medicare
outlier payment rate; expand certain NTAP criteria definitions so more new technologies are eligible for and receive the add-on; and establish a formal appeals process for manufacturers denied an NTAP determination.
* High average
outlier payment amount per beneficiary.
The final rule also includes an
outlier payment policy that will pay facilities more for patients whose care is significantly more costly than the Medicare payment amount.
CMS will continue to use the hospital's total charges for all inpatient services provided during a patient's stay when determining whether the case qualifies for an
outlier payment.
Claims that Tenet Healthcare fraudulently abused the Medicare
outlier payment system resulted in a high-profile $900 million fine.
Medicare sets the
outlier payment formula based on the most recent Medicare cost report submitted by the hospital.
This study explores how Medicare's
outlier payment adjustment for home health care influenced treatment intensity and discharge status for home health patients.
According to McClellan (1997), the effects of the
outlier payment system on the power of the PPS are substantially larger than might be conveyed by its 5 percent share (see Newhouse, 2002).
Hospitals can also qualify for additional payments under
outlier payment policies, depending on the hospital's actual charges.
Models that better match costs modestly decrease this risk, and the retrospective payment model and the
outlier payment policies reduce risk most
[(Standard Base Amount).sub.Geographic_Adjusted] * [DRG.sub.WEIGHT] + (
Outlier Payment) + Passthru + IME + DSH (4)
The analogous high-cost
outlier payment is a fraction of costs after the case passes a threshold.