What is post-payment review?
A post-payment review is when the insurer audits documentation after a claim has already been paid.
Why do reimbursement rates vary regionally?
Insurance contracts and fee schedules differ by geographic market.
How do hospital and surgeon payments differ?
Hospitals are reimbursed under separate facility payment systems, while surgeons are paid under professional fee schedules.
What is a DRG?
A Diagnosis Related Group is how inpatient hospital stays are categorized for reimbursement.
What is an APC?
Ambulatory Payment Classification is used for outpatient hospital services.
Can insurance policies conflict with federal law?
Medical policies must comply with federal law, but interpretation differences sometimes result in denials that require appeal.
What is the No Surprises Act’s role in reconstruction?
It protects patients from certain out-of-network balance bills when services are provided at in-network facilities.
What is the Qualified Payment Amount (QPA)?
The QPA is the insurer’s median in-network rate used as a reference in dispute resolution under federal law.
What is Independent Dispute Resolution (IDR)?
IDR is a federal arbitration process between providers and insurers when out-of-network payment disputes arise.
Does the patient participate in IDR?
No. It occurs between the insurer and provider.