Allen Bibb, Keysor Kathryn J
American College of Radiology, Reston, VA 20191, USA.
J Am Coll Radiol. 2005 Nov;2(11):896-905. doi: 10.1016/j.jacr.2005.05.012.
Keeping up with the technical and academic advances in medicine of the past 2 decades has made studying the US government's physician reimbursement system a low priority for most physicians. However, in the current environment of declining physician reimbursement and increasing frequency of compliance audits by Medicare, it is important for all physicians to have a basic understanding of the Medicare payment process. A major component of the physician payment system occurs at the local level. Through local coverage determinations, state Medicare contractors make more than 90% of all Medicare coverage decisions. Federal law requires Medicare contractors to seek physician input into their coverage decision process through contractor advisory committees, and through these committees, physicians can have significant influence over the coverage decision process. Once local contractors have made their coverage decisions, the covered indications for a procedure or treatment are published for the provider community. At that point, it becomes the responsibility of physicians to know the covered indications for certain services, because contractors will deny claims for services that are not linked to covered indications. This review focuses on the basics of the local Medicare payment process, with emphasis on the development of local coverage decisions by contractors. This understanding will allow physicians to positively influence the local reimbursement process.
跟上过去20年医学领域的技术和学术进步，使得研究美国政府的医生报销系统对大多数医生来说优先级较低。然而，在当前医生报销费用下降以及医疗保险合规审计频率增加的环境下，所有医生对医疗保险支付流程有基本的了解很重要。医生支付系统的一个主要部分发生在地方层面。通过地方医保覆盖范围确定，州医疗保险承办商做出了超过90%的医疗保险覆盖范围决策。联邦法律要求医疗保险承办商通过承办商咨询委员会征求医生对其覆盖范围决策过程的意见，通过这些委员会，医生可以对覆盖范围决策过程产生重大影响。一旦地方承办商做出了他们的覆盖范围决策，某一程序或治疗的被覆盖适应症就会为医疗服务提供者群体公布。在那时，了解某些服务的被覆盖适应症就成了医生的责任，因为承办商会拒绝支付与未被覆盖适应症相关的服务费用。本综述聚焦于地方医疗保险支付流程的基础内容，重点是承办商做出地方医保覆盖范围决策的过程。这种理解将使医生能够积极影响地方报销流程。
