LP4 Assignment: Physician Reimbursement
• What are the different methods that MCOs reimburse providers for health care services?
There are a variety of options available employers have for compensating providers. There is the Non-Risk-Based Physician payment used by all types of Payers which includes:
• Fee-For-Service: a payment method where the provider is paid a fee for each procedure performed and billed. There are straight charges; Usual, customary, or reasonable (UCR) allowances; percentage discount on charges; fee schedule; relative value scale (RVS); resource-based relative value scale (RBRVS); Percent of Medicare RBRVS; Special fee schedule or RVS multiplier; Facility fee add-on (pg. 122)
• Case rates and global fees: A case rate is single payment that includes all professional services provided in a defined episode of care. (pg. 128).
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Unbundling is when a provider bills multiple procedure codes that would normally be billed as a global procedure code. At the company, I work for, the claims department has programs that can identify when unbundling has taken place by the provider.
Then there is the risk-based physician payment used by HMO’s which includes:
• Capitation-A set amount of money received or paid out to HMO’s based on membership instead of services rendered. Capitation is expressed in dollars per member per month (PMPM). (pg. 296) (Variation factors, PCP only, Global, etc.)
• At-risk fee for service – HMOs pays doctors according to what procedures are used to treat a