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The IPF PPS is a program from CMS (Centers for Medicare) that pays psychiatric hospitals and psychiatric units for patient care. The Medicare Inpatient Psychiatric payment rates are intended to vary based on actual patient resource use and costs. The Inpatient Psychiatric Facility (IPF) PPS pays a federal per-diem base rate for each day of a psychiatric stay, adjusted for patient factors (age, select MS-DRGs, comorbidities) and facility factors (wage index, rural, teaching).

The End-Stage Renal Disease Prospective Payment System, is how Medicare pays dialysis facilities. ERSD PPS functions as a single bundled rate per treatment that covers renal dialysis services, drugs, labs, and supplies. For CY2026, the base rate is $281.71 per treatment, adjusted for patient case-mix and facility-level factors such as the wage index and low-volume status. This guide breaks down what's included in the ESRD bundle, how the per-treatment base rate is set, the ad

Every Medicare inpatient stay is paid through the DRG Payment System. Get the DRG system right, and the claim pays correctly. Get it wrong, or miss a transfer or a payer downgrade, and the payment is off, often without anyone noticing. Micro-Dyn's DRG grouper and pricing engines assign, price, and validate the DRG on every claim, so payment is accurate the first time. This guide explains how DRG payment and reimbursement work, where you may be losing money, and how to keep ev

The Skilled Nursing Facility PPS pays a per diem rate for each day of a covered stay, as set under the Patient-Driven Payment Model (PDPM). PDPM classifies each patient across five case-mix components plus a non-case-mix component, and adjusts three of those components by day of stay. This guide breaks down why SNF payments are under PDPM, the case-mix components that drive the rate, how the per diem is built, and the role of the MDS assessment. 🔄 From RUG-IV to PDPM (why i

An Ambulatory Surgery Center (ASC) is a healthcare facility where patients receive same-day surgical care without an overnight hospital stay. Medicare pays ASCs under the ASC payment system, which sets rates for an approved list of covered surgical procedures and is closely tied to the hospital outpatient OPPS/APC framework. Below, we cover what an ASC is, how it differs from a hospital outpatient department, and exactly how Medicare reimburses ASC procedures. 📌 What "ASC"

IRF-PPS reimbursement pays inpatient rehabilitation facilities a predetermined amount per discharge, based on the patient's Case-Mix Group (CMG). Under the IRF Prospective Payment System (IRF PPS), the CMG is derived from the patient's IRF-PAI assessment; its relative weight is multiplied by a standard payment amount and then adjusted for comorbidity tier, facility-level factors, and short-stay or transfer situations to reach the final payment. This guide breaks down what a C

Healthcare cases and revenue cycles are impossible to predict completely. Patients regularly arrive with a seemingly simple primary diagnosis, only to escalate into a completely different level of severity and coding. After their case escalates, they require extended stays, additional interventions, and resources that far exceed the cost of their original DRG classification. APR DRG pricing was built to handle this complexity, but managing outlier cases can be a large fiscal

Quick answer: Inpatient status means a patient is formally admitted to the hospital, while outpatient status covers services delivered without a formal admission - even if the patient stays overnight for observation. The distinction matters because inpatient claims are priced under the Inpatient Prospective Payment System (IPPS/MS-DRG) and outpatient claims under the Outpatient Prospective Payment System (OPPS/APC), which changes how much is paid and who pays it. The classifi

Sicker Patients, More Complex Pricing: Advanced APR-DRG Pricing Strategies for High-Acuity PatientsInpatient cases vary in complexity, as do their reimbursements. Cases that require more intensive intervention, include multiple comorbidities, or necessitate an extended stay can create a more complex road to reimbursement. As the acuity of a patient's condition rises, so do the stakes of reimbursement. When hospitals, health systems, and payers process claims, it's vital that

Burnout seems to be a major issue in every healthcare organization. Between handling compliance, administrative burdens, and the intensity of patient care, it's difficult to stay afloat. Though an administrative role may seem protected from stress, payer contract managers often struggle to balance workflows. Overextended payor contract managers are responsible for negotiating rates, managing fee schedules, tracking reimbursement terms, and catching payment discrepancies. Even

Quick answer: Medicaid claims pricing varies by state because each state administers its own Medicaid program and sets its own payment methodologies - many using APR-DRG for inpatient and EAPG for outpatient, but with different base rates, weights, and policy adjustments. That state-by-state variation is why a single national pricer is not enough; accurate Medicaid pricing requires state-specific methodologies kept current. Medicaid's pricing looks different depending on wher

Quick answer: Reference-based pricing (RBP) sets payment as a multiple of a benchmark - usually Medicare rates (for example, 140% of Medicare) - instead of negotiating discounts off hospital chargemaster prices, which is how traditional commercial claims pricing works. RBP gives payers and self-funded plans more cost control and transparency, but it requires accurate Medicare pricing as the reference point. The way some healthcare services are processed and priced is changing

In a complex healthcare system, payer contracts are only as effective as the system surrounding them. Payer Contract Managers are often overwhelmed with rate negotiation, fee scheduling, and reimbursement terms. What a contract says will occur and what is actually reimbursed is often very different. The potential for pricing gaps in the payor contracting process is a large opportunity for revenue loss. When healthcare organizations understand claims pricing, they can more eas

Quick answer: APR-DRG pricing reimburses inpatient claims based on how the patient is classified - the All Patient Refined DRG assigns each stay a base DRG plus a severity-of-illness and risk-of-mortality subclass (levels 1 to 4). Because payment scales with that severity classification, accurate coding and grouping directly determine reimbursement; under-captured severity means underpayment. When two patients are admitted to the same facility with the same primary diagnosis,

In this article, we'll dig into how ABNs work, and how Micro-Dyn may be able to help your revenue processing handle them. ❓ What's An Advanced Beneficiary Notice? In hospital billing, Medicare may not cover some costs. When costs aren't covered by Medicare, someone still needs to pay them! However, patients also need advance notice that their Medicare won't cover services. That's when a medicare beneficiary receives an ABN, or an advanced beneficiary notice of non-coverage. T

Description: Ensure accurate medical billing compliance! This checklist helps streamline healthcare claims processing, provide accurate reimbursements, avoid denials, and simplify coding audits. 🧾 Healthcare Claims Pricing Checklist: A Guide for Payers and Providers for Reimbursement Integrity Ensuring compliance in the healthcare revenue cycle can be complex. Throughout the billing process, payers and providers are looking out for claim denials, costly audits, and coding er

Healthcare providers perform countless billable services every day. Behind the scenes, these billable services must travel a path from point of care, through charge capture, into the hospital's charge master, and finally becoming a clean claim. This path is full of opportunities for revenue to disappear. Any seemingly small amount of revenue leakage can multiply over time, resulting in millions of dollars lost. 💡 What is Charge Capture? Charge capture is the process by which

⚠️ Transfer DRG Pricing Errors: What Your Analytics Should Catch In revenue cycle management, transfer DRG pricing presents a minefield for risk. While outright claim denials trigger more obvious alerts, transfer DRG underpayments can more easily go unnoticed. With transfer DRGs, modest lost revenue can quickly build up to thousands! Placing aside the potential for a costly audit, transfer DRG recovery is an expensive process in and of itself. Transfer DRG review often requir

Healthcare revenue cycle management is a complex network. RCM describes the financial operations process in healthcare, from the moment a patient makes a doctor's appointment to complete insurance reconciliation. The goal is accurate reimbursement for payers and patients for healthcare services provided. When each piece of the process is working smoothly, payers, patients, and healthcare services all receive what they're owed. A strong RCM process means that medical billing

Revenue leakage is a frequently overlooked financial threat to healthcare organizations. In contrast to claim denials or clear billing errors, revenue leakage often goes unnoticed until it accumulates into thousands of dollars in lost reimbursement. As hospitals use APR-DRG grouping systems, even minor inaccuracies can compound into systematic underpayment over time. When busy staff have to fight these inaccuracies with detailed coding checks, that can cost time and money too