In a previous post, I mentioned CMS as well as a grouper of payers and providers pledged to increase their share of claims paid under value based reimbursement (VBR) schemas such as ACOs and bundled payments and away from fee for service. That’s all fine and well but how will corresponding IT systems on both payers and providers handle these claims in both the preparation, adjudication at the payer, and retrospective analysis with the least amount of manual intervention possible? Oh, and the data has to be accurate. And timely.
In a previous WEDI conference where Geisinger presented some of their then current challenges with the bundled payment model. Since they are both a provider and plan, the plan part negotiated a price for a type of service for one of their employer groups such as knee replacements. The employer recognized a good portion of their covered employee and dependent population had received these in the past and since they are a self-insured group, had paid quite a bit in these claims. Just like Costco and Sam’s Club, the employer had negotiated a bulk discount rate for knee replacements for their employees and dependents and not the previously contracted fee for service rate. This sounds easy enough in real life but here were a few of the challenges that Geisinger faced in processing these claims:
1) How does the adjudication system know which claims are all a part of the particular event? In the case of the knee replacement surgery, there are multiple visits leading up to the diagnosis, the pre-op, surgical event, post-op, and follow-up care. What happens when the patient has to go to multiple providers for this one event? In this case, the provider sees a PCP first; then the orthopedic surgeon; the PT/OT for rehab; and then maybe some DME for home care.
2) What happens if the care occurs with providers that are non-par but the member does not have an alternative? How will this non-par provider get paid? How will this payment impact the pre-negotiated price of the service? How can the actuaries determine the negotiated rate if this is unknown?
3) How is the reimbursement divided up amongst the different providers especially if the providers are not financially a part of the same health system or group practice?
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