Value Based Reimbursement
Value Based Reimbursement
The Value Based Reimbursement (VBR) suite of solutions enables health plans to maximize the effectiveness of their medical expenditures by paying for value (vs. volume) and by incenting team-based performance. It automates the assembly of care teams/networks, the design and contracting of reimbursement policies, and the selection and calculation of the appropriate reimbursement for all provider services.
This integrated approach drives administrative cost reduction and significantly improves provider payment accuracy. The VBR suite allows payers to adopt a phased migration by simultaneously supporting traditional and emerging methodologies. Additionally, by centralizing all reimbursement including claims pricing, P4P incentives and capitation in one platform, the VBR suite accelerates provider transparency and buy-in.
Business Challenges
- Intense regulatory and employer pressure for higher quality care at a lower cost
- Payment for new care delivery models such as PCMH and ACO
- Increased employer demand for VBID, VBP and custom/tailored products
- Realizing product performance goals by driving the required network performance (health, financial)
- Mandated MLR caps, ICD10 and other regulatory changes
- Efficient implementation of emerging payments methodologies such as global, bundled, episodic, etc.
- Claims systems limitations in supporting team-oriented reimbursement policies
Key Features
- Drill-down analytics for network and provider segmentation
- Automation for network/care team design and customization to support products and care models
- English-like reimbursement policy designer for traditional/emerging methodologies and incentives
- Automated contract authoring, customization, offering, modeling, codification and loading
- Rules-driven reimbursement standards enforcement
- Flexible, visual configuration of reimbursement selection rules to ensure that the correct reimbursement is used for every provider service
- Configurable, high-performance reimbursement engine
- End-to-end audit trail and corresponding analytics for selection and pricing transactions
- Reimbursement Analytics to monitor payment trends and their correlation to provider performance (Future Release)
Key Benefits
- Increased compliance with MLR and administrative cost caps through decreased reimbursement administration costs
- Reduced medical expenditure and/or reduced rate of growth of medical expenditure through optimal mix of reimbursement methodologies to drive network/provider performance
- Strengthened competitive posture through differentiated product design and performance
- Decreased provider-related claims mis-payments
- Increased provider adoption of new care and payment models
Solution(s)
Provider Contracting
Provider Selection
Integrated Reimbursement
