News & Updates

February 17, 2016

Medicare Payment Differentials Across Outpatient Settings of Care, Avalere, February 2016

Medicare beneficiaries can receive the same services in different outpatient settings, yet various providers in those settings can receive different payments for that care and beneficiaries can face different cost-sharing amounts. For example, a Medicare beneficiary could receive a colonoscopy in the hospital outpatient department (HOPD), an ambulatory surgical center (ASC) or a physician office. Each setting of care has its own Medicare payment system as defined in statute and implemented by the Centers for Medicare & Medicaid Services (CMS), and can result in significant differences in Medicare payment rates for many services.

The purpose of this white paper is to assess Medicare payment differentials for episodes of care across the HOPD and physician office setting for three services commonly provided in outpatient settings: cardiovascular imaging, colonoscopy, and evaluation and management (E&M) services. We also examined payment differentials for the ASC setting as part of our colonoscopy analysis. We began by reviewing published literature for prior studies addressing this issue, and then performed our own analyses of episodes of care using Medicare claims data.

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