Discussion This Chapter Question & Answer Guide (With Explanation)

This type of question evaluates analytical and critical thinking skills.

What This Question Is About

This question relates to discussion this chapter and requires a structured academic response.

How to Approach This Question

Use appropriate theories and support your answer with clear reasoning.

Key Explanation

This topic involves discussion this chapter. A strong answer should include explanation, application, and examples.

Original Question

The Discussion for this chapter is taken from the Advanced Exercises in the Student Workbook. Outpatient Prospective Payment System versus Ambulatory Surgical Center Payment System Reimbursement Levels (Level 5—Evaluating) As you have seen in chapters 5 through 7, Medicare has different payment systems associated with various healthcare settings. In this chapter, you have learned about the hospital-based outpatient setting. This system is not used in the Ambulatory Surgical Center (ASC) setting; rather a modified version of this payment system is used and is called the ASC payment system. Both systems use APCs, but provisions, adjustments, and payment rates are different. Medicare designates which procedures are safe for the ASC setting. In this exercise, we examine a cataract procedure (CPT code 66984) which is one of the most performed procedures for Medicare beneficiaries. This procedure is approved for both the hospital outpatient and ASC settings. Genie is a 68-year-old female who presents with age-related incipient cataract of the right eye (ICD-10-CM code H25.011). She recently met with her physician about cataract surgery. The physician indicated that she needs extracapsular cataract removal with insertion of an intraocular lens prosthesis (CPT code 66984). Dr. Williams told Genie that she could have the procedure in an outpatient hospital facility or an ambulatory surgical center (ASC). Let’s examine the reimbursement and cost sharing amounts for each setting. CPT Code Outpatient Hospital Facility Ambulatory Surgical Center Reimbursement Cost-Sharing Reimbursement Cost-Sharing 66984 $2,021.86 $404.38 $1,012.72 $202.54 Rates as of January 2020 As you can see, the reimbursement and cost sharing amount for the hospital-based outpatient facility is almost twice the amount required for the ASC facility. It is the same procedure, provided by the same physician (Dr. Williams) regardless of setting. For you Initial Discussion Post, respond to each of the following questions: Is the quality of care two times better in the outpatient hospital facility setting? Are the outcomes of care two times better in the outpatient hospital facility setting? Are the costs of providing services and care that much lower in the ASC setting? Are Medicare beneficiaries aware of the disparity of cost-sharing amounts in different surgical settings? Is it fair to charge different cost-sharing amounts for the same service? Do you think the difference in cost-sharing would influence your decision for where to have surgery?

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