The Hospital Outpatient Prospective Payment System (HOPPS) is a payment system that was established in August 2000 by government legislation to create prospectively set payment rates for designated hospital outpatient services. It is administered by the Centers for Medicare and Medicaid (CMS).

“Incident to” services are defined as services that are furnished as an integral, although incidental, part of a physician’s professional services in the physician’s office (whether located in a separate office suite or within an institution) or in a patient’s home.^1,2 In the Medicare program administered by the Centers for Medicare and Medicaid Services (CMS), auxiliary personnel such as pharmacists; nurses; and nonphysician practitioners (NPPs) like physician assistants, nurse practitioners, or clinical nurse specialists can provide some services traditionally performed by physicians in certain practice settings under incident to services arrangements.^1,2 These services must be part of a patient’s normal course of treatment and are billed by the CMS-recognized provider under that provider’s National Provider Identifier (NPI).^1,2

MACRA is legislation signed in April 2015 that is designed to transform the basis of health care clinician payment from volume to value.¹ MACRA created the Quality Payment Program (QPP), which repealed the sustainable growth rate formula used to determine physician and other clinician FFS payment rates in Medicare as well as creating the MIPS.^2,3 It also created bonus payments for entities participating in APMs.

A Medicare Administrative Contractor (MAC) is a private health care insurer responsible for managing policies and processing Medicare Part A, Medicare Part B, and durable medical equipment (DME) claims for Medicare Fee-For-Service (FFS) beneficiaries.¹

The Medicare Shared Savings Program (Shared Savings Program or MSSP) is a program developed by CMS in 2012 that enables providers and suppliers of health care such as physicians and hospitals to set up an accountable care organization (ACO). The Shared Savings Program is a novel Medicare payment model which shifts away from the focus on volume-based reimbursement metrics and toward improved patient outcomes and increased value (value-based care). Under the MSSP, the ACO is charged with serving an assigned FFS Medicare beneficiary population, with a focus on improving patient outcomes while reducing cost of care. The Shared Savings Program holds ACOs accountable to certain standards while providing patient care, including quality, cost, and patient experience. These metrics are tied to the ACO’s reimbursement for services provided.