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Managed Care Decomposition Analysis MCDA. Comparative Reimbursement Analysis and Contract Optimization. Introduction.

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managed care decomposition analysis mcda

Managed Care Decomposition AnalysisMCDA

Comparative Reimbursement Analysis

and

Contract Optimization

introduction
Introduction

In today’s Managed Care environment, expected reimbursement is a function of Managed Care Organization (MCO) specific rules that are executed at the patient-level based on each patient’s characteristics as defined in the MCO’s contract. The goal of Managed Care Decomposition Analysis (MCDA) is to clearly define and quantify this expected reimbursement process in terms of patient characteristics (master attributes) and expected reimbursement (reimbursement attributes) so that the healthcare executive may identify and potentially optimize net income within existing managed care contract parameters.

slide3
Marketing Product Lines

Clinical Product Lines

MarketSpace

ChargeMaster

Hospital Patient Population

Shift to

Managed

Care

MCO brings in New Patients

and Proposed Contract

Predicted MCPL’s

MCOContract

Master

MCO Contract Accepted

(Payor Specific)

Inherent MCPL’s

slide4
How Contracts Are Interrelated:

MCO Contract

Master

Patient Characteristics

Reimbursement Characteristics

What are the MCPL’s defined

by the contracts?

How are the MCPL’s reimbursed?

A patient or patient group can have

more than one reimbursement possibility

based on characteristics.

A patient or patient group can have

more than one characteristic.

slide5
Contract Negotiation

Predicted Patients

Offered Contract Rules

Predicted Reimbursement

slide6
Contract Monitoring

Actual Patients

Contract Rules

Expected Reimbursement

slide7
MCO Contract

Master

Patient Characteristics

or MCPL’s

Reimbursement Characteristics

  • Percent of Charges
  • Per Diem
  • Time Sensitive Per Diem
  • Discharge Amount
  • Line Item Amount
  • DRG
  • UB-92 REV Code
  • CPT-4 Code
  • ICD-9-CM Code
  • Covered Charges

How

much?

What?

slide8
Managed Care Decomposition Analysis

MCO Contract

Master

Actual Patients

MCDA Data Base

Contract Rules

Patient Characteristics

Reimbursement Characteristics

Managed Care

Product Lines

Expected

Reimbursement

Reimbursement Attributes

Master Attributes

How is it being purchased?

What is being purchased?

slide9
Managed Care Decomposition Analysis

Contract 1

Contract 3

Contract 2

Contract n

Hospital Contract

Management System

MCO Contract

Master

MCDA defines this as

. . .

Patient Characteristics

Reimbursement Characteristics

1. Define what is currently happening

2. Define alternative reimbursement scenarios from MCO Contract Master

that, if implemented, could increase net income

3. Extract all patient characteristics as defined in MCO Contract Master and

identify potential net income opportunities based on these characteristics

slide10
Example:

Payor Decomposition Analysis

slide12
Reimbursement

Attribute

Master Attribute

slide13
Reimbursement

Attribute

slide14
Reimbursement

Attributes

slide17
Managed Care Decomposition Analysis

The OSI Standardization process allows MCDA encoded hospitals to be aggregated into

a Managed Care Data Repository for future comparative analyses.

. . . .

MCDA

Hospital n

MCDA

Hospital 3

MCDA

Hospital 1

MCDA

Hospital 2

OSI Attribute Encoder

Managed Care Data Repository

Managed Care Product Lines

Standard Reimbursement Attributes

Standard Master Attributes

Standard

Payors

management care decomposition analysis benefits
Management Care Decomposition AnalysisBenefits
  • The identification and definition of MCPL’s based on the current expected reimbursement
  • environment.
  • The quantification and ranking of expected reimbursement incidents by Master Attribute
  • and payor.
  • The identification and quantification of alternative reimbursement scenarios by Master
  • Attribute.
  • The compilation of a detailed Master Attribute catalog outlining the various reimbursement
  • scenarios that are possible based on standard payor and associated Reimbursement Attribute.
  • .
  • The creation of an MCDA database that can serve as a basis for expected reimbursement
  • simulations and budgeting.
  • The identification of statistically relevant clinical correlation's between existing Standard
  • Master Attributes.
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