NVCC MPFS And OPPS Models Example Paper And Presentation

Week 2 – Fee SchedulesFee Schedules are important in healthcare and are not just for Medicare. Commercial Payors base their
contracted rates (rates that they negotiate w/ hospitals) off of the Fee Schedules. There are two MPFS
and OPPS.
For this Assignment you will write a paper and corresponding presentation giving an overview of the
two systems as well as building example models of each (MPFS and OPPS). It is your choice on which
disease state and treatment to build models (you must build two examples for MPFS and two
examples for OPPS). I am only looking for single treatments here in your models. I do not care how you
build your model but at the end of this document there are some examples. It is up to you to decide
how to build it. There are many examples out there. But, you must do the research. This is complicated.
Do not reach out to me if you have not some research and feel you have hit a brick-wall. It is ok to reach
out to me, but if I feel that you have not tried, you will receive a zero for the assignment.
Overview: Medicare, Medicare Advantage, Part D, Medicare Supplement, Medicaid, Affordable Care Act
Explained

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This is a good overview video that might include a lot of what you learned in HAP 301
Watch: How Are Doctors Paid? Learn the Incentives in Physician Compensation

Watch: How Doctor Relative Value Units (RVUs) Work – Secret to How Doctors Get Paid

Watch: Doctor Pay: RVUs Determine Income

Now for the modeling
Note: there is also a look-up tool online if you don’t want to work w/ the addenda. But there is more
information in the addenda and working w/ the full datasets will give you a more complete picture. The
choice is yours.
https://www.cms.gov/medicare/physician-feeschedule/search?Y=0&T=4&HT=0&CT=3&H1=33503&M=5
For the MPFS
https://www.cms.gov/medicare/medicare-fee-for-service-payment/physicianfeesched
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https://www.cms.gov/medicaremedicare-fee-service-paymentphysicianfeeschedpfs-federal-regulationnotices/cms-1770-f
Download the zip file w/ the addenda
https://www.cms.gov/files/zip/cy-2023-pfs-final-rule-addenda.zip
For the OPPS:
https://www.cms.gov/medicaremedicare-fee-service-paymenthospitaloutpatientppshospitaloutpatient-regulations-and-notices/cms-1772-fc
Download the zip file w/ the addenda
https://www.cms.gov/license/ama?file=/files/zip/2023-nfrm-opps-addenda.zip
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Addenda A will give you drug pricing (line up a disease state w/ a drug treatment), include the
costs and is organized by APC
Addenda B will give you drug pricing based on HCPCS code. This is more relevant. It is much
easier to line up diagnosis code (ICD-10) w/ a treatment code.
Don’t worry about the other addenda
In your model be sure to include definitions of each field, the purpose is to show that you know
the fields that CMS is using to publish the data
For the MPFS model be sure to include a summary of GPCI and include that in your workup.
You should use Excel and use the built-in VLOOKUP to reference the GPCI. This means that you
will specify where your practice is, e.g. STATE to get the relative weights.
o Be sure to identify all fields, e.g. what does PE GPCI mean
Examples:
MPFS
Coronary Bypass Surgery
CPT Code = 33503
RVUs = 22.51
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OPPS
Now you are going to hate me….since Medicare is running out of money, they have also introduced a
conversion factor to further bring payments down. You will need to include this in your modeling and
you need to explain all of this in your paper and presentation. It is important that you have a full
grasp of every element. The good news is that once you learn it, you don’t have re-learn it. Just pay
attention to the changes that come out every year, and understand their significance. I will be looking
for these points in the last part of your paper and presentation.
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