Paying Providers Flashcards
Medicare “bonus” and “penalty” payment
At the end of each year, actual spending for all hip and knee surgeries will be compared with a target. If actual spending is less than the target, the hospital may receive an additional payment “bonus” from Medicare. If actual spending is more than the target, the hospital may have to pay Medicare a “penalty”
Hsiao fee schedule
Based on Hsiao’s analysis of “work” of different procedures:
a function of time spent, mental effort and judgment, technical skill and physical effort, and stress
Provides a relative rating of “work” for these procedures, and dollar value ratios assigned accordingly by Congress (public healthcare) or private insurers (private healthcare)
Private insurers find a reason to avoid paying __% of bills.
Private insurers find a reason to avoid paying 30% of bills.
This may be reduced to as low as 15% with a good office department to make the case for you.
Fee-for-service model
Model in which physicians are paid per service they provide.
This is where the fee schedules come into play. The Hsiao one is also called the Resource-Based Relative Value Scale (RBRVS), and is used for Medicare.
Same applies for hospitals, but there is additional cost for service and overhead.
Capitation model
Per-patient pay rate model. Can be applied to physicians and to hospitals.
Per-episode-of-illness model
Procedure, pre-op, and post-op all nestled into one payment
Salary
Pre-time-spent
Per diem pay
Model for hospital pay. Hospitals paid per day that patient spends in hospital
Per admission pay
For hospitals. Hospitals paid per hospital admission.
DRGs
Diagnosis Related Groups, the model of per admission hospital pay that Medicare uses.
Lumps diagnoses into one category and sets a payment for that category, which is provided to the hospital after discharge.
Bonus vs withhold
Bonus: Extra payment at a certain time of year which may be supplied if x condition is met
Withhold: Money held back for a certain time, such as a year, and is given to physicians or hospitals if certain goals are obtained. (ex, a plan may withhold 10% of all payments to physicians until the end of the year and only give it to the physician if they meet x condition)
Both may be based on categories of total revenue, utilization, patient satisfaction, and quality.
Capitation dollar flow model
Add-ons to capitation that limit financial risk
- Carve outs (certain diagnoses or categories, like mental health, don’t fall into the payment plan)
- Risk adjusted payments (Capitation payments higher for higher risk payments)
- Size of risk pool (more patients, more consistency)
- Stop-loss insurance (protects against high-cost patients)
You are the medical director for a physician group whose physicians are paid a fixed salary for the number of sessions they are scheduled to be in clinic. You want to try to maximize the revenues generated by physician visits, and you are considering changing how you compensate the physicians. Which of the following is most likely to increase revenue from physician visits?
Per visit (fee-for-service)
True/False: A multispecialty medical group with PCPs and specialists that is paid by an insurer with capitation payments is likely to emphasize coordination of care across primary care physicians and specialists.
True
