Transcript Managed Care Contracting Under ICD-10

Maryland AAHAM Education Conference
January 17, 2014
Linthicum, MD
Managed Care Contracting Under ICD-10
Rob Borchert, MBA, CRCE-I – Best Practice Associates
Lorrie Borchert, CPC, CRCE-I – Best Practice Training Institute
Learning Objectives
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Review of ICD-10 Impacts!
Review of ACA components! (2014 and beyond)
Discussion of various Contract Types!
Discussion of new Exchange Contracts!
How to perform various analyses!
What will payors do?
What should YOU do?
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ICD Code Difference
CM - Clinical Modification
PCS- Procedure Coding System
100000
80000
90000
70000
80000
60000
70000
50000
60000
40000
50000
30000
40000
20000
30000
10000
20000
0
Series1
10000
1 9
ICD
ICD2 10
13000
68000
0
Series1
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ICD-9
2 10
ICD
11000
87000
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Mapping Between Old And New Systems
• General equivalence maps (GEMs) between ICD-9CM and ICD-10-CM/PCS have been developed
• GEMs do NOT equal crosswalks
• Reimbursement map added to CMS web site in
2009
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Intended for use by payors
Temporary mechanism
Allows claims processing by legacy systems
Allows for data collection for reimbursement changes
• Maps should NOT be used for coding medical
records
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Mappings
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GEMs Mapping
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CMS GEMS vs. CMS Reimbursement
Mappings
Source: Deloitte Consulting presentation “Do Not Underestimate ICD-10’s Impact on
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Associates
Population
Health Management” at the Forum 10 in Washington, DC 10/15/10
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When should GEMS be used?
• To convert databases such as:
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Payment systems
Payment and coverage edits and policies
Risk adjustment logic
Quality measures
Disease management programs
Utilization/case management systems
Financial modeling
Variety of research applications involving trend data
• To translate coded data for comparing data across transition
period
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When should GEMs NOT be used?
• When you have access to the medical record?
• When you have access to text descriptions or
clinical terms describing diagnosis or procedure
• When a small number of codes are being
converted
• GEMs should NOT be used for coding medical
records!!!!
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Sports Medicine
Hit by a ball - ICD-9-CM code: E917.0
ICD-10-CM possible code
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W21.00 – Struck by hit or thrown ball, unspecified type
W21.01 – Struck by football
W21.02 – Struck by soccer ball
W21.03 – Struck by baseball
W21.04 – Struck by golf ball
W21.05 – Struck by basketball
W21.06 – Struck by volleyball
W21.07 – Struck by softball
W21.09 – Struck by other hit or thrown ball
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ICD-10-PCS Code Structure
ICD-10 PCS Code Structure:
Root
Operation
Section
1
2
Body
System
3
Approach
4
5
Body
Part
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Qualifier
7
Device
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ICD-10-PCS Example
Interphalangeal fusion of right great toe,
percutaneous pin fixation
OSGP34Z
Section
Med/Surgical
0
Body System
Lower Joints
S
Root Operation
Fusion
G
Body part
Toe Phalangeal
Joint - Right
P
Approach
Percutaneous
3
Device
Internal Fixation
Device
4
Qualifier
None
Z
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Impacts to People
Source: AAPC website
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Impacts to Process
• Documentation practices
• Productivity and efficiency practices
• Contracts and business processes
• HIM practices
• Practice management processes
• Budget
• Payment conversions
• System logic and edits
• Claims edits
• Disease & Utilization management
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Impacts to Process
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Impacts to Technology
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IT system changes
Upgrade software
Modified field lengths
Modified system logic
Update superbills/encounter forms and databases
Data reporting elements
Submitting ICD-9 and ICD-10 codes
Retain access to historical coded data in ICD-9 format
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Revenue Cycle Impacts
Clinical
Business Process/
Patient Access
Patient Access Services
PreRegistration
Patient Financial Services
Claims
Processing
Charge
Capture
Entry
Scheduling
Registration
Account
Resolution
Financial
Counseling
Coding
Assignment
Pricing
Payment
Posting
Clinical
Intervention
Test Order
“Optional”
Clinical
Doc.
Scheduling
IT Applications
Charge/Coding Integrity
HIS
(including
CPOE)
Claims
Clearinghouse
HIM
Patient
Accounting
Utilization
Management
Case
Management
Patient
Accounting
Performance
Measurement
Medium Impact to process and training
Large impact to process and training
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Contract Management and
Insurance Verification
• Building coverage patterns from TPP contracts
• Specific specialty definitions of both CPT and
diagnosis (Case Rates)
• HIPAA Transaction sets
• Educating and Training staff for optimum
coverage in identifying both POA and principal
reason for admission (medical necessity)
• TPP systems monitoring
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ICD-10 Effect on Payor
Reimbursements
• Independent analysis of some of the most common reimbursement
arrangements identified conversion challenges that may modify some
payor and provider reimbursement arrangements, while for others the
effect will be minimal.
• Solutions to these situations need to be tailored to your specific
environment; however, you will want to review the possibilities identified
in the analysis outlined in the table below.
• In cases such as diagnosis-related group carve outs where codes have a
relatively small impact on reimbursement formulas, most payors will likely
experience few conversion problems.
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ICD-10 Impact on Payor
Reimbursements
Common
Reimbursement
Arrangements
DRGs and other
case rates
Potential ICD-10 Impact Identified by Independent Analysis
Hospitals, government, and commercial payors
Code focus: ICD-9 and procedure codes
1. ICD-9 diagnosis and procedure codes are the basis for diagnosis-related groups (DRG) classifications.
2. Using General Equivalence Mappings (GEMs), a number of ICD-10 codes did not map easily to the MSDRGs (inpatient reimbursement); the clinical review process was required to complete the conversion
process. GEMs are a tool to help find matches between ICD-9 and ICD-10 codes.
3. The ICD-10 MS-DRGs will likely produce some different reimbursement results compared to ICD-9-based
MS-DRGs, for example: a. Clean mapping problems
b. Service frequency, billed code volume, impact on dollars
c. Clarity of ICD-10 code may produce a different code assignment based on the original ICD-9 code
d. Dollar and volume magnitude related to the changes to Complications Comorbidities (CC)/ Major
Complications Comorbidities (MCC) lists are unknown
4. The Inpatient Psychiatric Facility Prospective Payment System for psychiatric facilities and Medicare
Severity Long-term Care DRG for long-term hospitals both use the same MS-Grouper and will be similarly
affected.
5. When applying CMS-designed ICD-10 MS-DRGs to a commercial population, the case mix may vary more
than the Medicare population does.
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ICD-10 Impact on Payor
Reimbursements
Common
Reimbursement
Arrangements
Potential ICD-10 Impact Identified by Independent Analysis
Risk-adjusted
Reimbursement
Medicare/Medicaid programs Code focus: Hierarchical Condition Categories (HCCs) and Rx-HCCs
1. Although more than 5,500 ICD-9 diagnosis codes on the HCC and Rx-HCC models have no ICD-10
map, HCC developers will be able to include the conditions in the ICD-10 HCC without altering the
intent. The largest potential impact is that more than 1,000 HCC ICD-9 codes have more than one ICD10 option.
2. The ICD-10 transition impact will be quite evident in situations where one ICD-10 code maps to more
than one ICD-9 code and either the ICD-9 codes do not map at all to a HCC, or to the same HCC.
DRGs/inpatient care
rate carve-out, passthrough or add-on
technology procedure
or diagnosis
Commercial insurers Code focus: DRG inpatient payment carve-outs where payment is negotiated
1. Diagnoses carve-outs are typically paid by broad category with little reliance on coding specifics to
differentiate payment levels.
2. Expect minimal impact on procedural coding because inpatient patient carve-out procedures and
technology are often reimbursed as a percentage of charges. Outpatient procedures are reimbursed
based on Current Procedural Terminology (CPT) codes where additional information is not needed to
pay a claim.
Episode-based
Reimbursement
Demonstrations (ACE – Acute Care Episode) and other pilots
While there have not been many systems reimbursing on episodes of care based on ICD-9 codes, the
advent of ICD-10-specific codes will likely accelerate the development of these payment types.
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ICD-10 Impact on Payor
Reimbursements
Common
Reimbursement
Arrangements
Potential ICD-10 Impact Identified by Independent Analysis
Performance-based
Reimbursement
Health plans, Medicare Pay for Performance (P4P)
Code focus: Healthcare Effectiveness Data and Information Set (HEDIS) and similar performance
measures
1. The most common structures are based on either reaching specified performance level or degree of
improvement. The transition to ICD-10 may affect HEDIS-based outcomes as HEDIS uses ICD-9
diagnosis and procedure codes along with other codes such as CPT and revenue codes. In the case of
immunization codes, ICD-9 codes are more specific than the ICD-10 mapping (five ICD-9 codes would
now map to two ICD-10 procedure codes). Because these ICD-10 codes are less specific, the small
portion of immunizations occurring in an inpatient setting will be unidentifiable under ICD-10, and this
may affect performance measurement.
Hospital Billed Charges
Hospitals
Code focus: billed charges, CPT/HCPCS
1. The conversion to ICD-10 should have minimal impact on billed charges because predecessor ICD-9
codes were not used to create the charges.
Usual and Customary
Reimbursement (UCR)
Payors, hospitals, and providers
Code focus: diagnosis codes
1. Diagnosis codes are used to help determine the payment rate and facilities’ qualification as inpatient
rehabilitation facilities (IRFs). Therefore, the initial conversion to ICD-10 will have some impact on
reimbursement based on IRF-Prospective Payment System (PPS). The challenge will be in determining
which ICD-10 codes are the qualifying codes that should be included in the IRF logic.
2. The increased specificity of ICD-10 codes will influence the IRF-PPS model in the future.
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ICD-10 Impact on Payor
Reimbursements
Common Reimbursement
Arrangements
Other Reimbursement
Arrangements
Potential ICD-10 Impact Identified by Independent Analysis
Brief summary
Resource Utilization Groups (RUGs): Minimal if any impact on skilled nursing facilities and
RUGs.
Home Health Resource Groups (HHRGs): Although many of the HHRG diagnostic categories are
broad, there will be some instances where HHRG assignment for the same condition may vary
under ICD-10 compared to ICD-9 diagnosis codes.
Possible future conversion of the CPT/HCPCS codes to ICD-10 PCS parallel with the CPT/ HCPCS
codes.
Source: Zenner, Patricia. ICD-10 Impact on Provider Reimbursement. Milliman, 2010. Retrieved from
http://publications.milliman.com/publications/health-published/pdfs/icd-10-impact-provider.pdf.
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Examples of I-9 to I-10 Conversions
Crohn’s Disease
ICD – 9 (4)
ICD – 10 (28)
Regional enteritis of small
intestine
555.0
K50.00
Regional enteritis of large
intestine
555.1
PLUS an
Regional enteritis of small
intestine w/ large intestine
555.2
ADDITIONAL
Regional enteritis of
unspecified site
555.9
27 CODES
ICD – 9 92.27
Implementation or insertion of
radioactive elements
ICD-10 PCS
261 PCS codes for Anatomical sites specified
21 distinct Approaches
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MCC/CC Category Conversion
Conversion Summary
MCC
CC
Total
ICD-9-CM Codes on List
1,592
3,427
5,019
ICD-10 CM codes Auto-translated
3,152
13,594
16,845
DRG
Description
# ICD-9 codes
291-293
Heart Failure & Shock
27
20
231-236
Coronary Bypass
9
232
250-251
Percutaneous Cardiovascular
Procedure without Stent
8
136
258-259
Cardiac Pacemaker Device
Replacement
6
14
533-534
Fracture of Femur
14
273
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# ICD-10 codes
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Managed Care Today
• Fully examine the rates you have today!!!!!
– MSDRG rates
– Case Rates for inpatient
– APC/APG Rates for outpatient surgery and
ancillary support services
– Per diem rates for various services
– Percent of charge rates for various services
– Discount off Medicare rates
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Managed Care Tomorrow
• Insurance Products under ACA:
– No ability to deny or limit coverage for pre-existing
conditions
– No lifetime limits on benefits
– No ability to cancel coverage without proof of
fraud
– Ability of patients to demand reconsideration of
health plan decision to deny payment for test or
treatment – includes an external appeal process
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Managed Care Tomorrow
• Insurance Products under ACA:
– Cost-free preventive services – access to
screenings/vaccinations & counseling without
deductible or co-insurance
– Kids on parent’s plan until reach age of 26
– Must be able to choose your primary care
physician – no need for referral to OB/GYN
– Use nearest ED without penalty or no requirement
to get prior approval and no higher deductible or
co-insurance for out-of-network ED visits
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Managed Care Tomorrow
• What payers will seek from providers under
BOTH Affordable Care Act (ACA) and ICD-10:
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medical decision making models
capitation models
quality measures and payments
bundling payment
patient-centered medical homes
• As a provider, can YOU bring your Quality and
Cost factors to the table FIRST?
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10 Considerations for
Building a Pricing Strategy
Make margin decisions NOW
Gather competitive pricing from all sources
Use market research to understand trade-offs consumers are willing to make
between price versus service
Assess the value to you of a loss leader
Calculate customer value profile to include transaction and downstream
Scrutinize cost reports for accuracy
Inventory your “soft selection” factors
“Sell” the organization’s pricing strategies to physicians and staff
Identify and follow enterprise metrics
Set your market position
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Medical Decision Making Models
• Not all services are created equal
• We do too many unnecessary things and don’t do
enough of the good stuff
• If something costs more, you are less likely to buy
• If something costs less, you are more likely to buy
• If you have already paid, you feel entitled to it
• Patients are interested in what happens to them
• The best treatment for a given individual may
depend on their own goals and values
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Value-Based Benefit Design
Low Cost – High Value
• Identify high value services
that are underused
– Screening
– Prevention
– Evidence based chronic
disease management
– Prenatal care
• Reduce or eliminate cost to
access
• Offer to payor for increased
market share
Costs more – Learn more
• Identify preference sensitive
and supply sensitive services
for which evidence suggests
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Coronary revascularization
Back surgeries
Cross sectional imaging
Large joint replacements
• Center of Clinical Excellence
• Patient Preference = High Value
• Should Cost More
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Value-Based Benefit Design
No Co-Pay – High Value
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Immunizations
Pregnancy
Hypertension
Asthma
Diabetes
Coronary Heart Disease
Congestive Heart Failure
Depression
Center of Clinical Excellence =
High Value
• Surgery for BPH
• Arthroscopy for OA at knee
• Knee and hip replacement
surgery
• Hysterectomy for DUB,
fibroids
• Some CT, MRI and PET scans
• Invasive treatments for
angina
• Endoscopy for GERD
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Capitation
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Utilization
Visits/PMPM
Days/1000
OP Procedures/1000
Referrals/1000
Lab/VISIT
Unit Cost
• Cost per IP Day
– Medical
– Surgical
– ICU; Intensive Care
• Cost per Consultant
• Cost per IP service
Capitation = Fixed Payment per Member per Month (PMPM)
for Block of Covered Services
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Shared Decision Making
• Provides an incentive to patients to use patient
decision aids that intersect with affected areas
• Make entire library of patient decision aids available
to patients and providers
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Product Pricing on the
Health Benefit Exchange
• New population – individual and small group plans
• Little to no experience regarding the populations
• Some states will have only 1 plan on the exchange,
others, like Colorado, may have as many as 800 plans
with 17 carriers participating
• Some plans may be trying to acquire market share
by offering very low cost plans (less than $200/month
for basic benefits)
• May be some new entrants into the health insurance
market in your state
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Key Aspects of Quality Measures
and Payments
• Share patient information across the continuum
of care and across the network of providers –
while maintaining confidentiality;
• Capture and compute accurate costs of care;
• Track clinical outcome data in relationship to
services provided;
• Assure longitudinal collection and storage of
patient information;
• Support the use of clinical protocols and
guidelines to improve quality and contain costs.
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Bundled Payment Models
• Model One: Retrospective
Acute Care Hospital Stay ONLY
• Model Two: Retrospective
Acute Care Hospital Stay PLUS
Post-Acute Care (end either
30, 60, or 90 days post; can
select up to 48 clinical
condition episodes)
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Bundled Payment Models
• Model Three: Retrospective
Post-Acute Care Only (end
either 30, 60, or 90 days post;
can select up to 48 clinical
condition episodes)
• Model Four: Acute Care
Hospital Stay Only (hospital,
physicians, and others)
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Bundled Payment Models
Flexibility
• Under models where there are choices of
episodes of care to be bundled, organizations
can choose which episodes they wish to bundle
• Will take data, time, and benefit to get providers
to sign up for Models 2 to 4
• Some health plans are bundling now – such as
vaginal deliveries
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Typical Errors in Contract Modeling
• Overall systems integration – lack of consolidated
database to share payor information experiences for
such as “case rates”, etc.
• Chargemaster increases – tracking and tying into
contract renewals due to independent Managed Care
system and/or lack of communication between Finance
and Managed Care/PFS
• Costs of managed care portfolio – Service Line, Product
Mix, etc.
– Inpatient versus outpatient services
– Resource utilization within Service Line
– Resource utilization within Case Rate
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Typical Errors in Contract Modeling
• Changes in payor administrative policies or
procedures
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Coding policy changed that may vary by payor
Bundling of CPT codes
Claim edit programs
Changes in claim payment time frames
Changes in precertification policies
Typically vary by payor
• Legislative changes impacting product mix –
shifting of traditional government programs into
managed care models
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Typical Errors in Contract Modeling
• Unresolved payor denials
– Timeliness of receiving denials
– Time and cost to review and challenge by type
– Denial percentage factors into ongoing negotiations
• Payor operational inefficiencies
– Inability to credential/load and update physician info
– Auditing process; internal and external
– Underpayments, refunds and offsets
• Shift in payor mix cannibalization – new payors
entering market due to ACA Exchanges
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Patient-centered Medical Homes
“A model of primary care that is patient-centered,
comprehensive, team-based, coordinated, accessible, and
focused on quality and safety”
According to the American College of Physicians, “the most
effective way to realign payment incentives to support the
PCMH model involves incorporating three different
components:
1. a “bundled” monthly care coordination payment for
medical professional work occurring outside of face-toface patient visits;
2. a visit-based fee-for-service component; and
3. a performance-based component to reward the
provision of efficient, high-quality services”
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Managed Care Contracts
• “Evergreens”: review cancellation/termination
language and consider ending by September
30, 2014 for NEW contract under ICD-10
• Beware of amendments: payors will ‘slip’ in
amendments regarding the “implementation
of ICD-10” without full details of their
readiness and/or changes in their systems,
edits, medical necessity changes, payment
protocols
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Language to Question!
• “in preparation for the implementation of ICD-10,
we will process claims as usual and accept the
submitted codes. The reimbursement for the
year 2014 -2015 will be budget neutral, reflecting
no impact on XXXXX hospital”
• Similar language but with a twist – “…although
our processing protocols may have changed due
to ICD-10, reimbursement will be budget neutral
for 2014 – 2015”
• YOUR ANALYSIS MAY SHOW DIFFERENT
REIMBURSEMENT BENEFITS!
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Language to Add to a Contract
• With the discontinuation of ICD- 9 as of
September 30, 2014, the auditing of historical
claims will not involve any claims with initial DOS
over three (3) years old from review request date
• As of October 1, 2017, no claims with ICD-9
codes will be available for audit. Any open
claims with ICD-9 codes must be resolved by
January 1, 2018.
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Language to Consider!
• All new and/or modified system processing
changes to the payor system must be shown
to the hospital/practice and explained by the
payor. This includes crosswalks, medical
necessity edits, claim processing edits, etc.
• As of October 1, all claims will be processed
using ICD-10 codes and no crosswalks to ICD-9
will occur.
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HIPAAA Non-Covered Entities
ICD-10 Myths and Facts
“Because ICD-9-CM will no longer be maintained
after ICD-10-CM/PCS is implemented, it is in noncovered entities’ best interest to use the new
coding system. The increased detail in ICD-10CM/PCS is of significant value to non-covered
entities. CMS will work with non-covered entities
to encourage their use of ICD-10-CM/PCS”
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HIPAAA Non-Covered Entities
The ICD-10 Transition: Focus on Non-Covered Entities
Definition of “best interest”
• ICD-10-CM codes will provide expanded detail in injury
codes, which will help automobile insurance and workers’
compensation program coordinate payment
• ICD-9-CM codes will no longer be maintained once ICD-10
has been implemented. The ICD-9-CM code set will
become less useful and resources will be continually
harder to obtain after three years
• Not adopting to ICD-10 coding could lead to undue
hardship for non-covered entities’ provider. They will have
to translate from ICD-10 manually
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Medicaid Expansion
Arizona
Kentucky
New Mexico
Arkansas
Maryland
New York
California
Massachusetts
North Dakota
Colorado
Michigan
Ohio
Connecticut
Minnesota
Oregon
Delaware
Missouri
Rhode Island
District of Columbia
Montana
Vermont
Florida
Nevada
Washington
Hawaii
New Hampshire
West Virginia
Illinois
New Jersey
Kansas and South Dakota – undecided as of May 2013
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Health Exchange Background
State Decisions for Creating Health Exchanges
Declared State-Based Exchange (16 States + D.C.)
Planning for Partnership Exchange (7 States)
Defaulted to Federal Exchange (27 States
Source: http://kff.org/health-reform/state-indicator/healthinsurance- exchanges/#map. Dated May 28, 2013.
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Health Exchange Background
Coverage Requirements and Tiers
An exchange must offer a plan choice in each of the five categories, which are based on the actuarial value of the plan.
The actuarial value is based on the average cost share of covered health expenses reimbursed by the plan for
the typical population.
In a given state, a participating payor must offer at least one Platinum or Gold plan.
The ACA also states that the federal government will select at least two multistate carriers available in every
state and every exchange.
The plans must provide the 10 essential health benefit (EHB) categories in total, as defined by CMS. However,
states can require a higher level of benefits.
The federal subsidy is indexed on the value of the Silver tier.
Gold (80%)
Catastrophic
(Under 30 or Qualify for Exemption)
[No Subsidy Provided]
For example, a Gold plan would cover the equivalent of $2,000 for an average patient’s
$2,500 in annual medical expenses. Higher coverage requires higher premiums.
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0% to 133% of FPL
Eligible for Medicaid
[If State Expands
Program] DSH may
also be effected
Description
100% to 250% of FPL
Eligible for CostSharing Support.
Basic Health Plan
(133% to 200%)
100%
133%
150%
200%
133% to 400% of FPL
Eligible for Health
Exchange Subsidy
[Sliding Scale Subsidy
as Tax Credit]
250%
300%
400%
Individual1
$11,490 $15,282 $17,235 $22,980 $28,725 $34,470 $45,960
Family of Four1
$23,550 $31,322 $35,325 $47,100 $58,875 $70,650 $94,200
Insurance Premium Cost
Target Percentage of Income2
2.0%
2.0%
4.0%
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6.3%
8.1%
9.5%
9.5%
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IV. Exchange Plan Premiums
State Differences
California
Covered California
Description
Regions
• 19 regions, largely along
•
Health Plans
county lines.
Rural counties were
grouped together.
Blue Shield of California
plans are offered in all
19 regions.
Kaiser is offered in 18 of 19
regions.
• Between three and six
•
•
The whole state is a single
region.
Maryland
Maryland Health Connection
• The whole state is a single
•
• 13 plans participating.
• Anthem Blue Cross and
•
Coverage
Vermont
Vermont Health Connect
plans are offered in all
19 regions.
There is an average of 4.5
plans offered in any given
region.
Average of 12 hospitals
and 2,000 physicians per
region.
• Two health plans will be
•
region.
There will be six navigator
regions.
13 health plans will be offered.
offered.
Blue Cross Blue Shield of
Vermont and MVP
Healthcare.
• Each plan will offer two
Bronze, two Silver, one
Gold, and one Platinum.
Vermont is building to a
statewide universal health
insurance coverage model.
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• All plans will be offered
•
throughout the state.
Provider networks will vary by
health plan.
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Provider Exchange Financial Impact
Analyzing the impact of payor mix changes will depend on several key assumptions
• Develop a current status view – revenue and
profitability by payor
• Project anticipated payor mix changes
– How much volume will shift to the exchanges?
– How much additional Medicaid?
• Project anticipated reimbursement
– Sensitivity analysis on the range of reimbursement
possibilities
– Percentage of current Medicare or commercial rates
• Determine potential impact on profitability
• Negotiate rates for exchange products based upon how
much margin reduction can be tolerated
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Contract Questions
• What types of contracts will your
organization be offered from the
payors?
• What type of analysis are the
payors doing regarding your
clinical experience?
• Do you want contracts based on
their data or YOURS?
• Will other contract types be
offered?
Next!!!
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FFS
• Outpatient
• Physicians
Case • MSDRGs
Rates • Am Surg
• Inpatient
Per
Diem • Distinct
Services
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Preferred Contract Approach
• A new contract allows for the
greatest flexibility to
– Define clinical protocols
– Negotiate rates
– Limit terms (audits, take-backs, length,
etc.)
• Does not interfere with current
contracts
• Establishes strength based on payor
history and the challenge to change
• Your data shows profitability under
new approaches!
@Best Practice Associates
Value
based
Contract
ICD-10
Case
Rates
Bundled
Services
Risk/Cost
based
Contract
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Summary of Next Steps!
• Perform Profitability Analysis by Payor!
• Identify “Evergreens” with lowest profit and determine
termination requirements!
• Perform an ICD-10 Financial Analysis for both inpatient and
outpatient!
• Review current Contract language for revision!
• Openly discuss New Contract options!
–
–
–
–
Value-based Purchasing
Bundling with Physicians or without Physicians
Risk/Cost based Contracts
Other Considerations
• Draft a “data-supported” White Paper!
• Conduct a meeting with Finance and Managed Care!
• MOVE FORWARD!!!!
@Best Practice Associates
62
???QUESTIONS???
@Best Practice Associates
63
CONTACT INFORMATION
@Best Practice Associates
64