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Provider Reimbursement
Our goal in reimbursing providers is to provide affordable care for our members while encouraging quality care through best care practices and rewarding providers for meeting the needs of our members. Several different types of reimbursement arrangements are used with providers. All are designed to achieve that goal.Some providers are paid on a "fee-for-service" basis, which means that the health plan pays the provider a certain set amount that corresponds to each type of service furnished by the provider.
Some providers are paid on a "discount" basis, which means that when a provider sends us a bill, we have negotiated a reduced rate on behalf of our members. We pay a predetermined percentage of the total bill for services.
Some providers are paid a "salary" with a possible additional payment made based on performance criteria such as quality of care and patient satisfaction measures.Sometimes we have "case rate" arrangements with providers, which means that for a selected set of services the provider receives a set fee, or a "case rate," for services needed up to an agreed upon maximum amount of services for a designated period of time. Alternatively, we may pay a "case rate" to a provider for all of the selected set of services needed during an agreed upon period of time.Sometimes we have "withhold" arrangements with providers, which means that a portion of the providers payment is set aside until the end of the year. The year-end reconciliation can happen in one or more of the following ways:
- Withhold arrangements are sometimes used to pay primary care, specialty, referral or hospital providers who furnish services to members. The provider usually receives all or a portion of the withheld amount based on performance of agreed upon criteria, which may include patient satisfaction levels, quality of care and/or care management measures along with the financial performance of HealthPartners. Certain factors are measured to determine if the provider has satisfied the withhold criteria, such as patient satisfaction, survey results and compliance with industry standards for preventative services, clinical guidelines and care management.
- Sometimes the amount of the withhold that the provider receives is based upon "cost targets" for care expenses. If total care costs are less than the cost target, all or a portion of the withheld amount is returned to the provider after the end of the year. Such cost targets include "stop-loss" protections which reduce the chance that treating patients with costly illnesses will have a direct negative impact on the providers performance.
A provider may qualify to participate in a bonus program and receive additional payment if the provider meets certain performance criteria. Generally, these performance criteria are similar to the withhold criteria described above.
Some providers---usually hospitals---are paid on the "basis of the diagnosis" that they are treating; in other words, they are paid a set fee to treat certain kinds of conditions. Sometimes we pay hospitals and other institutional providers a set fee, or "per diem," for each day or according to the number of days the patient spent in the facility.
Occasionally, our reimbursement arrangements with providers include some combination of the methods described above. For example, we may pay a case rate to a provider for a selected set of services needed during an agreed upon period of time, or for services needed up to an agreed upon maximum amount of services, and pay that same provider on a fee-for-service basis for services that are not provided within the time period or that exceed the maximum amount of services. In addition, although we may pay a provider, such as a medical clinic, using one type of reimbursement method, that clinic may pay its employed providers using another reimbursement method.
Please check with your individual provider if you wish to know the basis on which he or she is paid.
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