Wiki APC - paying greater than charged

[daddlelee]

When reimbursing a surgical procedure under OPPS/APC, is there a Medicare requirement stating to pay up to the full value of the APC even if it is greater than the billed amount for the procedure?

 

[thomas7331]

Medicare does pay the OPPS rate even when it exceeds billed charge - the purpose of the OPPS payment methodology is that similar procedures that fall into the same classification are all paid at the same rate, so the reimbursement is calculated as an average for that class. So some will necessarily be paid at a rate that exceeds costs and some at a rate that is less than the cost, (which could exceed billed charges) but theoretically this will average out over the class as a whole. The whole logic of this payment system is that you'll win on some and lose on others but come out right in the end.

As far as a 'Medicare requirement' that you ask about, I'm not sure I completely understand the question. If a non-Medicare payer uses OPPS, they are not required to follow Medicare payment rules - the particular provider contract would dictate whether or not the payment could or could not be greater than billed charges.