Dealing with-case-rates

Dealing with Case Rates: Getting Paid for Higher

Acuity Visits and Proceduresby Olga Khabinskay

COO of WCH Service Bureau, Inc

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Changing Healthcare Industry • Payers want to pay capitation and global rates for services

• Insurances prefer Urgent care clinics - defray the cost of hospital visits • Insurance companies are the largest payers for urgent care services

• Patient want better access to care:• flexible visit hours• quick results• multispecialty care • less waiting time

• Urgent Care Business Model is the future of healthcare:• Medical practices merging • Hospitals buying practices• Panels are closing for new providers

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Everything Starts with Credentialing• Credentialing process: Facility vs. physician credentialing• Urgent Care Contract vs. Fee for Service

• Medicare, Medicaid and Medicaid Managed Care plans – fee for service model

• Evaluation and Management Contract• CPT codes 99201-99215. • Urgent Care Rates National Statistic: Best Rate: $175 Worst Rate: $85 Average Standard Rate: $120

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Decision on Reimbursement Model• In / Out of Network• Flat Rate with the hope : Pros and Cons• Carved- outs: Are they worth it?

• Fee for service: Pros and Cons• Quality of patient care using the models• Payers preference to pay global for visits – Why?

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Carve-out• What is Carve-out?• How carve-outs work?• What services are

appropriate to ask for carve out?

• What is payers realistic opinion?

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Limiting Defensive MedicineDefinition: Diagnostic or therapeutic measures conducted primarily as a safeguard against possible malpractice liability.Example: “A patient in her 60s fell and hit her head 5 days ago. She was having a headache. I couldn’t find a mark on her and was inclined to send her home with pain medications. But she was on Coumadin which put her at risk of bleeding. So I did a CT scan of her head to “make sure” that she didn’t have a bleed. She didn’t.”

Decisions, decisions, decisions……………….

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What are the risk by limiting defensive medicine ?

• Right Decision – All inclusive payment– Lack of payment– Patient responsibility

• Wrong decision– High risk doctor – high

malpractice rate– License sanctions– Exclusions from insurance

panels

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Flu Shots in Urgent Care• Boost to revenue : Community outreach /

school/ occupation medicine • Returning patients to the center• Patient preferred wayHow about getting paid for administrating flu shot?Global Billing / Fee for Service / Carve out/ Private pay

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Ethical Dilemmas• Flat Rate reimbursement limits fair ability for

patient care• Should I perform the test or send patient to

emergency room?• Lack of staff during slow hours• Lack of confirmatory lab results• What the center should do in complex situations?• What should centers should avoid doing?

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Getting Paid for Higher Acuity Visits• Fee for service model provides flexibility– timed codes delivery higher reimbursement– Tests and monitoring is allowed – Prolonged visits billing:

-99354 - 99355- 99356- 99357

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Getting Paid for Higher Acuity Visits• S9083 Global Billing Rate– All inclusive code for urgent care billing– Good for clinics with minor injuries and illnesses: cold, cuts,

bites, minor bruises– Acuity visits require either:

• Fee for service model• Out of network options• Private pay • Urgent Care Contract Negotiation

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Review of EOB

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Review of EOB

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Review of EOB

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Review of EOB

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• Hire experienced staff• Manager / Front desk/ Assistants

• Use Electronic registration and Verification• Billing electronically: In-house or Outsourced• Collecting copays and deductibles• Billing Patients is not an option

Strategies to improve reimbursement

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Solution for Getting Paid Better

• New centers should stick with Fee for Service Model• Matured Centers should negotiate or switch• Hiring Mid-level vs. Physician• Evaluating billing/reimbursement process every quarter• Mix Model might work the best • Contract Negotiation

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Urgent Care Industry Long-Term Concerns• Becoming the next Drive Thru Medical Care– Walk in Centers/ Retail clinics

• Limited diagnostic services• Less experienced professionals• Market competition • New fraudulent schemes• Pay for performance model: ACO’s Obamacare

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