Mc-Chpt 20 Ancillary Services (Reimbursement And Control)

Front 1

Types of Ancillary services:

Back 1

1. Diagnostic: laboratory; X-rays
2. Therapeutic.

Front 2

MCO’s data (“Info Mgmt”) must include:

Back 2

 type of service
 who ordered it
 cost of the service

Front 3

HOW TO CONTROL COSTS AND UTILIZATION OF ANCILLARY SERVICES
Modify Physicians’ Behavior
Deal with Physicians’ monetary motivations for high utilzation

Back 3

 trace ownership of equipment
 track unusually high rates of referral to a given provider
 analyze physicians’ utilization patterns
 ban self-referrals
 or, reimburse them at a low profit margin
 Define Indications for Use (standard protocols)
 only worthwhile for expensive ancillary services
 use Chart reviews
 Limit # of services authorized

Front 4

Difficulties in Reducing Physicians’ ability to use Ancillary services

Back 4

 could be medically necessary
 in rural areas, no choice of ancillary providers
 hard to find cheapest facility
 Physicians have legitimate nonmonetary concerns:
 to be diagnostically certain
 patient demands
 fear of malpractice claims

Solutions
 give feedback to physicians:
 comparisons to their peers
 feedback should be adjusted for age/sex

Front 5

Use Careful Contracting with Ancillary Service Providers

Back 5

 contract with a very limited network of Anc Providers
 Give providers financial incentives to control utilization
 (through Capitation, Performance-based Ffs, Withhold/Bonus)
 use Global Fees reimbursement
 use a capitated Ancillary Network Manager

Front 6

Difficulties in Capitating Ancillary Services:

Back 6

 Capitation under POS plans results in double-paying
 Need large volume of data to compute the capitation rate
 MCO must direct the ancillary services to the capitated providers.
 Best if the Ancillary Service is self-contained

Done.