Medicare Outlier Caps Change for 2010

In this months E-zine article, we discussed the changes that were made to outlier payments which became effective Jan 1, 2010. One of the interesting points that was brought up is how outliers were calculated prior to the changes. What was clear when writing the article was that outliers, while valuable to bridge the gap on high utilization on episodes, it never completely covered the cost in providing care. Some agencies have heard that many organizations have been using outlier payments to help increase their overall revenue intentionally. However, many times they are a cost of doing business. This is why there is additional reimbursement available to help accommodate for those situations.

The problem is that you only receive 80% of the difference of the additional cost associated for those services. If you would like examples of these calculations and definitions, please read our latest E-Zine article here. This is why it is important to always diligently assess the patient but at the same time, make sure you are addressing the correct utilization for the patient.

With Medicare now only allowing outlier payments to be made for those that equal 10% of the total PPS payments year to date of that claim, it will be wise to monitor and closely manage this practice. So remember, outliers should be exceptions to the rule and not the rule.

Jeff Brittain
CTO, Executive Vice President
Select Data

Tags: Medicare Reimbursement, Outlier Payments

This entry was posted on Friday, March 12th, 2010 at 12:16 am and is filed under Billing, Revenue Cycle Management. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.

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