GBA 113/114 Flashcards
Independent delivery network
Physician practices and a hospital system
What are the GSK customer Segments
Independent health care provider practice-privately owned businesses/retain autonomy
Institutional Segment
Public health segment
Emerging customers-retail Rx, occupational health facilities concierge practices
What do reimbursements influence
Clinical, economic and operational decisions made within health care provider practices and hospitals
What happens as a result of falling reimbursements
Many health care providers need to increase the volume of patients they see, the hcp has less time available to see reps office staff views reps as an obstacle to the office s efficiency
Forms of Independent health Care Practices
Solo practices
Group practices
Multi specialty practices
What are the fundamental economics of the independent healthcare provider
HCPs provide services to patients and are compensated based on a patients health benefit.the majority of patients have coverage under a commercial health plan or a public plan ie Medicare or medical although a small number pay cash.
Patients pay a copayment.remainder of the fees of the dr are reimbursed by the commercial or public plan.
What are the two largest streams of revenue in a hcp’s office.
Co-pays
Payer reimbursements
What are the ways hcp’s are reimbursed
Fee for service
Capitation
What is Fee for Seevice
Physician is paid for each service he or she provides. Provider sends a claim with their charge and is reimbursed physicians have an incentive to increase the number of services they provide on each visit, as well as the number of visits
What is capitation?
A fixed payment per month or PMPM. In contrast to fee for service payments per member per month is not based on the actual services. Compensation does not rise with utilization. Under a captivated regimen it is financially advantageous to carefully manage service utilization and control costs in order to maximize profits. Capitation transfers a degree of financial risk and reward to physicians.
Discuss the financial challenges of capitation
Capitation transfers a degree of financial risk and reward to physicians. The financial incentives encourage physicians to be more active participants in controlling utilization. From a health plan perspective, captivated arrangements are most effective when the lions share of enrollees utilize capitated groups for care. Health plans establish a relatively closed provider network in order to drive utilization toward capitated physician group. From a physician perspective a capitated system therefore locks in a membership base a revenue source.
What is P4P
Can be built In to fee for service or capitation. These mechanisms include some manner in which the Health Care provider can lose compensation or earn extra compensation
What are the most common mechanisms employed to increase or decrease physician compensation?
Withholds, fee adjustments and bonuses
What are Withholds?
For withhold, a health plan sets up a risk pool that holds a specified percentage of negotiated fees perhaps 20% for a given practice. If the practice charges for the year are less than an agreed upon amount, the plan dispurses the money in a withhold pool to the practice. If costs are higher the health plan retains the money .
Fee adjustments
Fee adjustments are employed as an alternative to or supplement for a withhold-under fee adjustment provisions, the health plan can unilaterally reduce fees in the event of cost overruns. Fee adjustments are most often used in HMOs or strongly managed PPO’s where risk is shared among a particating physicians.
Explain Bonuses
Bonuses are used most frequently with providers who play a gate keeper role, such as primary care physicians. Extra payments can be earned by keeping health an costs such as fees to specialists and hospitals below a budget or utilization target. Bonuses may also be based on patient satisfaction, access or outcomes.
Effects of P4P on physician compensation
Can increase or decrease physician compensation by more than 25% of charges
What are other revenue streams
Botox and concierge practices.
Who are the employees in a HCP’S office that have the most hands on involvement in the practice
Back office-most are related to billing.
Front end process
Middle process-
Back end/billing and collections
What are roles in the back office?
Practice Manager
admin Staff
Billing and reimbursement managers
Claims building and coding specialists
What do admin staff do?
Manage patient flow
Billing and reimbursement managers
Ensure that the practice is being reimbursed properly for the care provided by billing payers and patients.
What do claims. Billing and coding specialists Di
Submit claims for payment to payers and health plans
Billing patients
Dealing with insurance carriers and specialty pharmacy
Handling pre certifications
Handling reimbursement appeals
Managing collections, accounts receivable and aging receivables
New roles- patient advocacy, patient satisfaction and clinical education.
Key responsibility of back office staff
Seeking prior authorization for Rx product that health care provider would like to prescribe but that are restricted on the patients pharmacy benefit. Manage inventory and reimbursement.
GSK formulary disclaimer
Consumers may be responsible for varying out of pocket expenses depending on an individuals plan and formulary coverage does Mott imply efficacy and safety.
Receptionist
The field rep must convince the receptionist of the value they provide the receptionist a gate keeper and could be a barrier to seeing the prescriber.
Who is the most critical member of the back office staff.
Practice Manager
What happens if a claim is denied?
It could potentially mean more of of pocket cost for them. It could lead to frustration by the patient trying to identify why they got a bill for a medical procedure they thought was covered
How are practices being proactive
Understanding each patients financial condition before they come in for treatment.
Capturing more revenue whenever possible at pint of service
Offering charitable care discounts at the point of sale to appropriate patients
Helping patients understand how they pay their bills
Financially clearing patients at the point of sake based on their ability to pay to avoid collection efforts that will be unsuccessful
Health care reimbursements have declined how has this affected physicians
Tied to categories of drugs
Decline in reimbursement ie decrease in practice revenue change in practice policies
Public payers like Medicare underpay by 15%
