EXECUTIVE SUMMARY
Patients with capitated insurance plans, which give providers a flat fee regardless of how much care is provided, are increasingly presenting to registration areas.
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Once the cost of care reaches the cap, providers won’t receive additional reimbursement, so it’s important that patients are compliant with their care instructions.
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Automated reminders could reduce non-compliance with medications.
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Some hospitals have nurses monitor patient compliance on an outpatient basis.
A growing number of patients are presenting to registration areas with capitated insurance plans. These plans allow payment of a flat fee for each covered individual, regardless of how much care the individual receives.
“Because these types of plans essentially create a ‘budget’ per patient for care, providers want to ensure that their patient is well and healthy and that they are closely managing the cost of their care,” says Yaroslav Voloshin, vice president of revenue cycle advisory solutions at MedAssets-Precyse, an Alpharetta, GA-based firm specializing in revenue cycle services and technology. Once the cost of care reaches the cap, providers won’t be reimbursed for any additional care.
“Patient compliance is a big part of this, especially when it comes to taking medications,” says Voloshin. If patients don’t take their medications as prescribed, for example, they are more at risk of developing costly complications.
Automated reminders are one way that hospitals can improve compliance with medications. “Hospitals are also assigning nurses to help monitor patient compliance on an outpatient basis,” says Voloshin.
The goal is to manage capitated patients in the most efficient way possible, which lessens the possibilities of complications that would require hospitalization. “The industry as a whole is moving in this direction,” says Voloshin. “The goal is to manage wellness and avoid hospitalization as much as possible.”
Much revenue at stake
Amy Sherman, CRCP, director of patient access at Berlin-based Central Vermont Medical Center, worries that capitated plans will negatively impact the hospital’s bottom line.
“Some private practice physicians won’t take patients with this kind of payment structure,” she explains. If patients with capitated plans don’t see a primary care physician because they can’t afford to pay out-of-pocket costs, their condition might worsen. Some of these patients will end up in the emergency department or be admitted to the hospital.
“A hospital in network absorbs such great costs to care for very ill patients that it becomes a financial drain on organizations,” says Sherman.
Some systems lack resources to ensure distribution of correct reimbursement according to payer contracts. If a hospital has staff trained in proration rules, which can identify payments that are not following the contracted rate, and an underpayment department focused on capturing any shortfalls, “then you are in a great position,” Sherman says.
Smaller hospitals, however, must rely on individual billers’ knowledge and expertise about insurance remittance advice, which explain reasons for payment, adjustment, denial, and/or uncovered charges. “There is no easy way to identify [underpayments] without knowing your contracts and being able to identify when payments have not been advanced,” says Sherman.
It’s key to have staff to “push back and fight for corrected payments when appropriate,” Sherman says. Not every hospital does, however. Central Vermont Medical Center sometimes outsources high-dollar denials.
“Once appeals have been exhausted, we use a health law firm in Baltimore,” says Sherman. “This offers us a level of expertise not found in organizations that don’t have legal counsel.”
SOURCE
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Amy Sherman, CRCP, Director, Patient Access, Central Vermont Medical Center, Berlin. Phone: (802) 225-7560. Email: [email protected].
