The prospective payment system to hospitals for Medicare hospital s outpatients is called ___ and became effective on _________

The Centers for Medicare & Medicaid Services (CMS) implemented the hospital Outpatient Prospective Payment System (OPPS) as mandated by the Balanced Budget Act of 1997. This system replaced the previous cost-based reimbursement model. The effective date for the OPPS was August 1, 2000. The payment methodology is based on grouping outpatient services into Ambulatory Payment Classifications (APCs), which bundle services with similar clinical intensity, resource utilization, and costs. Each APC is assigned a relative payment weight that is multiplied by a conversion factor to determine the national payment rate for the services within that group.

A. APGs, October 1, 2000: While APGs (Ambulatory Patient Groups) are a similar classification system, the one adopted by Medicare for the OPPS is specifically named Ambulatory Payment Classifications (APCs).

B. RBRVS, January 1, 2000: The Resource-Based Relative Value Scale (RBRVS) is the prospective payment system used to reimburse for physician services under the Medicare Physician Fee Schedule, not hospital outpatient services.

D. DRGs, October 1, 1983: Diagnosis-Related Groups (DRGs) are the case-mix system used for the Medicare Inpatient Prospective Payment System (IPPS) to reimburse for hospital inpatient care.

1. Centers for Medicare & Medicaid Services (CMS). (n.d.). Outpatient Prospective Payment System (OPPS). U.S. Department of Health & Human Services. Retrieved from https://www.cms.gov/medicare/payment/prospective-payment-systems/hospital-outpatient-pps. (In the main body text

CMS states

"On August 1

2000

CMS implemented the prospective payment system (PPS) for hospital outpatient services...").

2. Casto

A. B. (2021). Principles of Healthcare Reimbursement (7th ed.). AHIMA Press. Chapter 6

"Outpatient and Ambulatory Care Payment Systems

" p. 136. (The text states

"The OPPS was implemented on August 1

2000... The OPPS utilizes the ambulatory payment classification (APC) system...").

3. University of Illinois Chicago

College of Applied Health Sciences. (n.d.). HIM 486 - Healthcare Data and Revenue Management Course Syllabus. "The OPPS was implemented on August 1

2000. The classification system for OPPS is Ambulatory Payment Classifications (APCs)." (This is a representative example of content covered in an accredited HIM program).