Managed Medicare Rates

Managed Medicare or Medicare Advantage contracts involve agreements between hospitals and commercial payers that administer Medicare-based plans for their members. These contracts may, but are not required to, base their payment methodologies on CMS reimbursement methodologies such as IPPS, IRF, IPF, SNF, OPPS, and MPFS.

Straight Medicare rates are not included in MRFs, as stated by CMS. Our focus is on the negotiated rates specific to Managed Medicare contracts to ensure transparency and compliance with CMS regulations.

Inpatient Prospective Payment System (IPPS)

Turquoise calculates the standard DRG rate for each hospital and DRG and incorporates any negotiated multipliers (e.g., 110% of the IPPS allowable). These calculated rates are included in the MRF to reflect the actual negotiated amounts as dollar values.

Inpatient Rehabilitation Facility (IRF), Inpatient Psychiatric Facility (IPF), and Skilled Nursing Facility (SNF)

Due to the complexity of these payment methodologies, Turquoise does not report the negotiated rate as a dollar amount. Instead, a description of the payment methodology is included in the MRF as a negotiated algorithm.

By January 1, 2025, an estimated allowed amount will also be included for these cases.

Outpatient Prospective Payment System (OPPS)

Turquoise calculates OPPS rates for all APCs, ASP drugs, DME, and lab codes for the hospital. These rates are included in the MRF alongside the relevant HCPCS and CPTs to provide comprehensive outpatient pricing information.

Medicare Physician Fee Schedule (MPFS)

For professional services, Turquoise calculates the facility rates from the MPFS. These rates are included in the MRF to reflect the negotiated amounts for professional services provided at the hospital.