The Changing Reimbursement Paradigm Shift

Green Dollars

Current medical payment and reimbursement structures involve the submission and payment of medical CPT® coded claims.  So, some doctors feel they need to “up-code” to maximize revenue; or “down-code” for fear of having a claim denied………Obviously, contradictory business goals bastardize the system into a payer versus provider tug-of-war, with patient care as a potential bargaining chip.

[By Dr. David Edward Marcinko MBA CMP™]

[By Prof. Hope Rachel Hetico RN MHA CPHQ CMP™]

Current medical payment and reimbursement structures involve the submission and payment of medical CPT® coded claims.

So, some doctors feel they need to “up-code” to maximize revenue; or “down-code” for fear of having a claim denied.

Moreover, this pay-for-quantity versus payment-for-quality philosophy is slowly being relegated to the past in light of current P4P, ACO and values based reimbursement initiatives; etc.

Tug-of-War System

Obviously, contradictory business goals bastardize the system into a payer versus provider tug-of-war, with patient care as a potential bargaining chip.

Instituting quality metrics should be included in this equation, and, a hybrid reimbursement model may be a viable option while integrating quality care metrics and reducing costs for all stakeholders.

A Two Tied System

This hybrid reimbursement system might use a two-tiered payment structure something like this:

  1. For the first payment, claims would be paid at hypothetical rate of 60% within one week of submission; partially decreasing office ARs, and favoring the time-value of money [TVM] equation.
  2. The second payment, consisting of the remaining zero to 40% of some total maximum allowable fee, is then paid quarterly. It would be based on scores like patient satisfaction, quality metrics, and stewardship of healthcare resources by analyzing a statistically valid sample of patient encounters taken from the electronic health record [EHR].

Green Dollars

Assessment

Such a hybrid payment system would remove unnecessary steps, like re-submitting claims and would lower the operational and administrative costs of healthcare claims processing.

These changes would decrease operational office costs and drive quality stewardship of the diminishing healthcare dollar.

Conclusion

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Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

Thoughts on an Emerging Hybrid [Two-Tiered] Medical Payment Model

by Editors

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