Health insurance plans and the new bundled payment systems for physical treatments including cardiovascular procedures shift from time to time. This scenario has presented hospitals and physicians to rethink their strategy when it comes to proving services to an individual with cardiology issues. The medical billers and coders who work on such claims need to verify it not once, but two to three times as it needs to be crystal clear as to where most of the reimbursement is getting drained or why is there a delay in payment posting.
Encounter based, bundled repayments have now appearing in the forefront of the national discussion on combating rising health care costs. The most preferred, fee-for-service model for reimbursement, hospitals, physicians, and post-acute care providers file distinct claims and are paid separately for provided services even when they are related to a single encounter of care.
But, but, but…. There’s a catch to this approach of payment as it encourages fragmented care, with little incentive for resource stewardship, coordination or communication across multiple providers. On the contrary, bundled payments seek to align the interests of providers by as long as a fixed payment for all services delivered during a single episode of care; this payment is distributed among all providers in a health care system involved with that patient, including hospitals and other facilities.
The medical billing team should also remember that although not a new policy initiative, bundled payments have resurfaced in the current era of health care reform with its advocates arguing that it can curtail health care costs while simultaneously improving quality.
Cardiology procedure and care is the area in which the implementation of bundled payments are arguably most visible and maybe most impactful. Many of the previous demonstrations of bundled payments have concentrated on and around cardiovascular conditions, and going forward it is likely that future efforts will continue to do so with good reason.
- Firstly, cardiology issues are common, costly, and deadly, and therefore, important to national discussions for health care reform.
- Secondly, care for cardiology procedures involves multiple provider chains ranging from different disciplines that include primary care, cardiac surgery, anesthesiology, and radiology.
- Lastly, cardiology patients can receive care in multiple health care settings such as hospitals, outpatient and primary care facilities, subspecialty clinics, skilled nursing facilities, solo physician facilities, etc.
Given all reasoning of the above factors, bundled payments have the potential to substantially improve care coordination and generate savings for cardiovascular care, but in the end, it also gives more payment options to physicians rather than hospitals.
To Present The New Bundle Payment Scheme In Simple Words…
- Bundled payments are a middle ground in the spectrum of health care payment models. On one side they are considered as a shift from the traditional fee-for-service model, where providers are reimbursed separately for each distinct service provided. However, bundled payments are not representative of global payments, or capitation, where a health care system is paid a lump-sum payment per attributed patient over a distinct time period, regardless of the number of distinct episodes of care.
- Additionally, payments are intended to encompass care across multiple cardiology conditions that a patient may require while each individual encounter of care is distinct and reimbursed separately in a bundled payment model.
- In this scenario, there are other alternative payment and delivery system reforms that fit between the extremes of fee-for-service and global payments on the spectrum of health care payment. These include value-based payments, where health systems or providers are given additional payments for high-quality care or levied financial penalties for poor quality care, and accountable care organizations where certain services or conditions may be covered in a capitated model, but other ancillary services may still be provided under fee-for-service.