Fee Schedules for Hospitals and Ambulatory Surgical Centers: A Guide for Policymakers

By Nicole M. Coomer

February 1, 2010 Related Topics: Ambulatory Surgery Centers, Fee Schedules

As health care costs for both hospital inpatient and outpatient and ambulatory surgical centers continue their rapid growth, policymakers and stakeholders are evaluating various means of medical cost containment in workers’ compensation. Often included as a part of this focus are updates to or the implementation of hospital and ambulatory surgical center fee schedules.

To provide policymakers and stakeholders with an understanding of how states regulate prices paid to hospitals and ambulatory surgical centers, this two-volume study documents the strategic design choices faced by regulators. It also details how different states have addressed those decisions.

The first volume, Fee Schedules for Hospitals and Ambulatory Surgical Centers: A Guide for Policymakers, provides details on strategic design choices:

  • Will there be hospital and ambulatory surgical center fee schedules? If yes, what general approach will be used?
  • What method of regulation will be implemented?
  • Will the regulation be Medicare based?
  • What will be the level of reimbursement? 
  • Will there be exceptions or exclusions?

A companion study, National Inventory of Workers’ Compensation Fee Schedules for Hospitals and Ambulatory Surgical Centers, provides a state by state inventory of the laws and regulations that address inpatient, outpatient and ambulatory surgical center prices. This useful reference book provides a general overview of each state’s regulations, allowing for easy comparisons of the regulatory approaches of several states as well as detailing the specific regulations of a particular state. 

These studies do not cover the extensive range of applications, interpretations or development processes used to develop the regulation decisions. Nor do they attempt to answer questions related to the effects of regulations in areas related to system costs 
or the effect on patient care.   

Illustrative findings:

Forty-one states impose some form of hospital or ambulatory surgical center (ASC) regulation, and many have regulations with unique aspects.
The most common forms of inpatient regulations – diagnosis-related group (DRG) based, percent of charges, and per diem – are used by over 75 percent of states with inpatient hospital price regulation.

The most common forms of outpatient reimbursement – ambulatory payment classification (APC) (group) based, percent of charges, and per procedure – are used by just over 75 percent of states with hospital outpatient price regulation.

More than half of the states provide a separate methodology for reimbursement for durable medical equipment, prosthetics, orthotics, and /or supplies. Although there is no consensus on this form of reimbursement, cost plus and Medicare-based reimbursement methodologies are used by roughly half of the states. Each report can be ordered separately.

WCRI Reports:

Fee Schedules for Hospitals and Ambulatory Surgical Centers: A Guide for Policymakers. Nicole M. Coomer. February 2010. WC-10-01.

National Inventory of Workers’ Compensation Fee Schedules for Hospitals and Ambulatory Surgical Centers. Nicole M. Coomer. February 2010. WC-10-02. 

Copyright: WCRI

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