Episodic Payment Bundle Processing System
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Solution Overview
Problem
Current healthcare payment systems are unable to transform fee-for-service claims into episodic payments in real-time during the adjudication process, leading to inefficient payment processing and delayed feedback on care utilization and quality, as they are designed to pay out claims at 100% and then require retrospective reconciliation.
Innovation Solution
A system and method for processing payment bundles that includes analyzing individual provider claims to determine if they are part of an existing payment bundle, creating patient events, and repricing claims accordingly, allowing for prospective episodic payments by identifying patient episodes and associating them with payment bundles, and modeling payment bundles using historical data to establish prices and distribution rules.
Engineering Contradictions & Design Principles
Engineering Contradiction Analysis
1Productivity
If current fee-for-service payment systems are used, then claims can be processed individually and paid out at 100%, but the system cannot transform claims into episodic payments in real-time and requires retrospective reconciliation
Solution Approach 1:
The system performs preliminary identification of payment bundles during the adjudication process by analyzing individual claims and determining if they belong to an episode of care. This allows the system to prepare episodic payment calculations in advance, transforming claims from fee-for-service to episodic payment structure before actual payment occurs, eliminating the need for retrospective reconciliation.
2Measurement precision
If retrospective reconciliation is used to transform fee-for-service claims into episodic payments, then payment accuracy can be achieved, but payment processing is delayed and feedback on care utilization is postponed
Solution Approach 1:
The system implements real-time feedback mechanisms during the adjudication process by continuously monitoring incoming claims, identifying episode of care patterns, and calculating appropriate episodic payments as claims are received. This provides immediate feedback on care utilization and payment status, allowing payers to track episode progression and payment accuracy in real-time rather than waiting for retrospective reconciliation.
3Ease of operation
If individual provider claims are processed separately under fee-for-service, then each claim can be evaluated independently, but collaboration among providers and care coordination are not stimulated
Solution Approach 1:
The system merges individual provider claims into episodic payment bundles by identifying relationships between claims from different providers and grouping them into cohesive episodes of care. This combining approach maintains the simplicity of individual claim submission while creating aggregated payment structures that align provider financial interests and stimulate collaboration, as providers are incentivized to coordinate care within the episode framework.
Data Source
AI summary
A system and process for prospectively creating patient episodes of care and triggering associated payment bundles during the claim adjudication process facilitates real-time claim pricing in accordance with payment bundle rules to facilitate episodic payment in place of pay-for-service payment. Additionally, various processes are described for modeling patient episodes and payment bundles and unbundling episodic payments.