Guided Notes
How Providers Get Paid: Reimbursement Methods
Fee-for-service, the Medicare Physician Fee Schedule and RVUs, APCs for hospital outpatient, MS-DRGs for inpatient, capitation, and value-based payment.
Payment models
Slide 1 / 5| Model | How it pays | Where used |
|---|---|---|
| Fee-for-service (fee schedule) | Per service, by a set price list | Physicians, most commercial contracts |
| Percent of charges | A percentage of billed charges | Some commercial/out-of-network |
| Prospective payment (PPS) | Fixed amount per case/visit set in advance | Medicare inpatient (DRG), outpatient (APC), SNF, home health |
| Capitation | Fixed amount per member per month (PMPM) | HMOs, some primary care |
| Value-based | Payment linked to quality/cost results | ACOs, bundled payments, MIPS |