How to Address Next-Gen Payment, Claims Management Systems

For example, a plan may have a policy stating: “When a member has a test, such as a preadmission lab test, followed by an elective admission, both the test and admission will be treated as a single episode.” But in the negotiation process, the payment policy may be disregarded in order to get a concession in another area or win in a particular facility.  Today’s payment systems lack the capabilities to adjudicate these types of variances to standard policies.

Policy enforcement can be another hurdle, especially when it comes to grouping separate claims—which may also stymie the payment system. A contract that was negotiated on a DRG basis may state that a re-admission within 30 days will be considered part of that DRG.  In this scenario, a plan could have a member who had a knee surgery and then was re-admitted for an infection due to that surgery, but if the contract did not specify that such an infection would be considered part of the DRG then the plan would pay additionally for the infection admission.

A very sophisticated system is needed to tie those two separate claims together and determine that they should be treated as part of the original admission and DRG.  This is beyond the scope of the vast majority of today’s systems.

Simply put, current payment systems were not designed to accommodate the ever-increasing complexities that are an outgrowth of the current negotiation process. The result is a payment environment that does not meet the needs of payors or providers. And this situation is likely to become exacerbated as we move towards a future of bundled payments, escalating regulation and ever-evolving reforms.