Dealing with Case rates = getting paid for higher acuity visits and procedures

1. Dealing with Case Rates:
Getting Paid for Higher
Acuity Visits and Procedures
by Olga Khabinskay
COOofWCHService Bureau,Inc

2. 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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3. 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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4. 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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5. 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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6. Limiting Defensive Medicine
Definition:
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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7. What are the risk by limiting
defensive medicine ?
• Right Decision
– All inclusive payment
– Lack of payment
– Patient responsibility
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• Wrong decision
– High risk doctor – high
malpractice rate
– License sanctions
– Exclusions from
insurance panels

8. Flu Shots in Urgent Care
• Boost to revenue : Community outreach /
school/ occupation medicine
• Returning patients to the center
• Patient preferred way
How about getting paid for administrating flu shot?
Global Billing / Fee for Service / Carve out/ Private pay
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9. 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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10. 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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11. 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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12. Review of EOB
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13. Review of EOB
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14. Review of EOB
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15. Review of EOB
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16. • 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
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Strategies to improve reimbursement

17. 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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18. 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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