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.
- Standardize the hospital's MCO contracts to allow for modeling and future comparative analysis
- Reveal alternative reimbursement scenarios that, if implemented, would increase net income
- Reveal alternative patient characterizations that, if implemented, would increase net income
- Quantify all alternative scenarios in terms of net income
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Charge Capture Audit provides a comprehensive, systematic approach for reviewing detailed patient bills for compliance to standard clinical guidelines and billing compliance rules. The key to CCA is our Clinical Rules Repository where we have constructed rule-sets for minimum (or expected) treatment levels for specific clinical product lines. We apply rules from our repository to your patient's clinical and financial information to identify those patients that are at variance with expected usage by clinical product characteristic. For example, for patients that are admitted with chest pain (as identified by the appropriate ICD-9-cm code) we would expect to see a Troponin or CPK ordered and billed. Another example would be: for patients that are discharged with an ICD-9 Code = 37.22 (Left heart cardiac catheterization) we would expect to see the appropriate cardiac catheterization charges on the patient's bill. Patients that do not conform to these and other CCA expected usage rules are flagged for review by hospital staff and/or our consultants
For more information Contact us for a free CCA white paper.