Learn from CMS' mistakes to guarantee outlier compliance
Health Care Auditing Strategies, September 1, 2007
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It's time to pay attention to outpatient outlier payments. CMS didn't, and it became the subject of a June 19 OIG audit report. Impact of Not Retroactively Adjusting Outpatient Outlier Payments states that the lack of retroactive adjustments to outpatient outlier payments negatively impacts the integrity of CMS' outpatient outlier program. CMS uses a prospective payment system for hospital outpatient services. Under this system, CMS reimburses outpatient providers, including hospital outpatient departments and community mental health centers (CMHC), based on predetermined, fixed payment amounts. CMS may make additional payments, called outlier payments, if the cost of care is extraordinarily high in relation to the average cost of treating comparable conditions or illnesses.
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