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The services are classified under a nomenclature based on the Current Procedural Terminology (CPT) to which the American Medical Association holds intellectual property rights. [2] Each service in the fee schedule is scored under the resource-based relative value scale (RBRVS) to determine a payment.
This information is translated into standardized codes through medical coding, using the appropriate coding systems such as ICD-10-CM and Current Procedural Terminology (CPT). A medical biller then takes the coded information, combined with the patient's insurance details, and forms a claim that is submitted to the payors.
For example, in 2005, a generic 99213 Current Procedural Terminology (CPT) code was worth 1.39 Relative Value Units, or RVUs. Adjusted for North Jersey, it was worth 1.57 RVUs. Using the 2005 Conversion Factor of $37.90, Medicare paid 1.57 * $37.90 for each 99213 performed, or $59.50.
Such coding is necessary for Medicare, Medicaid, and other health insurance programs to ensure that insurance claims are processed in an orderly and consistent manner. Initially, use of the codes was voluntary, but with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) use of the HCPCS for ...
A Health Reimbursement Arrangement, also known as a Health Reimbursement Account (HRA), [1] is a type of US employer-funded health benefit plan that reimburses employees for out-of-pocket medical expenses and, in limited cases, to pay for health insurance plan premiums.
“ERISA reimbursement” claims began arising in the late 1980s and have been resisted by some federal courts. [ 5 ] According to industry statistics, ERISA plans and related insurers are collecting close to $1 billion per year through the seizure of tort recoveries or other contractual payments received by insured personal injury victims. [ 6 ]
A cost-plus-incentive fee (CPIF) contract is a cost-reimbursement contract which provides for an initially negotiated fee to be adjusted later by a formula based on the relationship of total allowable costs to total target costs.
A cost-reimbursement contract is appropriate when it is desirable to shift some risk of successful contract performance from the contractor to the buyer. It is used most commonly when the item purchased cannot be defined explicitly, as for research and development , or for cases where there is not enough data to estimate the final cost accurately.