Coverage: Is determined by local or national policies of private or public payers identifying the conditions (based on ICD10 and CPT codes) and paying for medical and surgical expenses incurred by the insured IF the services meet the conditions outlined in said policy coverage plan. As such, coverage of a condition does not equate to full reimbursement of services (to the provider delivering the services) if certain conditions stated in the policy are not met. This is why it is important for providers and patients alike to understand such limitations, and to create programs that operate within these conditions to ensure proper reimbursement for these services.
Medicare coverage determinations help decide whether tests, items, and services may be reimbursed, and vary by location. Some services are covered regardless of location, but most are locally determined. Medicare coverage can be via national coverage determinations (NCDs) or local coverage determinations (LCDs).1
Reimbursement: Private health insurers or public payers (CMS, VA, etc.) may reimburse the insured for expenses incurred from illness or injury, or pay the provider directly for services rendered. It is often misunderstood that coverage of a condition equates to full reimbursement for these services. In actuality, reimbursement amounts depend on policies, restrictions and conditions that need to be met for a patient, as well as the appropriate use criteria that governs testing for the condition being treated.
Reimbursement amounts are based upon many factors, including estimates of the cost of a medical test, item, or service. Accurate estimation can be challenging for the actual costs of coronary computed tomography angiography (Coronary CTA) including patient coordination, beta blockade, nitroglycerin administration and monitoring, nursing support, technical support, physician oversight, monitoring and treatment for adverse reactions, and contrast media. The Medicare Physician Fee Schedule (MPFS) provides the professional component of reimbursement to the provider for services rendered to Medicare beneficiaries. The Hospital Outpatient Prospective Payment System (HOPPS) provides payment for the technical component of reimbursement (equipment, supplies, personnel) for services rendered to Medicare beneficiaries.
1 Your Medicare coverage. Available at https://www.medicare.gov/coverage/your-medicare-coverage.html. Accessed online Sep 19, 2016.