Bundled Amounts

Below multiple scenarios regarding episode detection and bundled amount pricing are described. The scenarios typically show how the happy flow process is envisioned and focus on a limited number of settings. In the first scenario a claim level episode detection is shown, while the second shows a claim line level example; in both scenarios, there is a lump sum pricing. The third scenario shows an override through exclude (so no episode). The fourth scenario gives an example how categories could lead to several payments.

Scenario 1 (Claim Level ⇒ Lump Sum)

The configuration below shows a straightforward detection of a hip replacement through a surgery plus includes at claim level:

Episode Definition

Code Description Scope

HIPREPL

Hip Replacement

Claim

Episode Criteria

Type In/Not In Procedure Group In/ Not in Diagnosis Group Match on Category

Trigger

In

(3340, 3341, 3342)

-

-

-

-

Include

In

(2201, 2202, 2203, 2204)

-

-

-

-

A bundled amount is configured as a lump sum:

Bundled Amount

Code Description Episode Definition Priced on Categories

HIPR-LUMP

Lump Sum for Hip Replacement

HIPREPL

Triggering

-

Provider pricing clauses are configured for different hospitals, paying different amounts:

Provider Pricing Clause

Provider Reimbursement Method Amount

St. John’s

HIPR-LUMP

$ 60000

St. Mary’s

HIPR-LUMP

$ 70000

The following claims are processed:

Claim 1

Line Provider Serviced Person Procedure Episode? Type Allowed Amount

1

St. John’s

John Doe

2794

Y

Include

$ 0

2

St. John’s

John Doe

3340

Y

Trigger

$ 60000

3

St. John’s

John Doe

5521

Y

Include

$ 0

Claim 2

Line Provider Serviced Person Procedure Episode? Type Allowed Amount

1

St. John’s

John Doe

1021

Y

Include

$ 0

2

St. John’s

John Doe

7651

Y

Include

$ 0

3

St. John’s

John Doe

2203

Y

Include

$ 0

Result

  • Claim line 2 in the first claim is identified as trigger; because the scope is 'Claim', the other lines are included as well. The price is put on the triggering line only.

  • Claim line 3 in the second claim is identified as include; because the scope is 'Claim', the other lines are included as well.

Scenario 2 (Claim Line Level ⇒ Lump Sum)

The configuration below shows a straightforward detection of a hip replacement through a surgery plus includes at claim line level:

Episode Definition

Code Description Scope

HIPREPL

Hip Replacement

Claim Line

Episode Criteria

Type In/Not In Procedure Group In/ Not in Diagnosis Group Match on Category

Trigger

In

(3340, 3341, 3342)

-

-

-

-

Include

In

(2201, 2202, 2203, 2204)

-

-

-

-

A bundled amount is configured as a lump sum:

Bundled Amount

Code Description Episode Definition Priced on Categories

HIPR-LUMP

Lump Sum for Hip Replacement

HIPREPL

Triggering

-

Provider pricing clauses are configured for different hospitals, paying different amounts:

Provider Pricing Clause

Provider Reimbursement Method Amount

St. John’s

HIPR-LUMP

$ 60000

St. Mary’s

HIPR-LUMP

$ 70000

The following claims are processed:

Claim 1

Line Provider Serviced Person Procedure Episode? Type Allowed Amount

1

St. John’s

John Doe

2794

N

-

-

2

St. John’s

John Doe

3340

Y

Trigger

$ 60000

3

St. John’s

John Doe

5521

N

-

-

Claim 2

Line Provider Serviced Person Procedure Episode? Type Allowed Amount

1

St. John’s

John Doe

2204

Y

Include

$ 0

2

St. John’s

John Doe

7651

N

-

-

3

St. John’s

John Doe

2203

Y

Include

$ 0

Result

  • Claim line 2 in the first claim is identified as trigger; because the scope is 'Claim Line' and no other line matches the criteria, the other lines do not become part of the episode. The price is put on the triggering line.

  • Claim line 1 and 3 in the second claim are identified as include, line 2 is not and is not automatically included because the scope is 'Claim Line'

Scenario 3 (Exclude)

The configuration below shows the same configuration as the first scenario, but extended with exclude criteria.:

Episode Definition

Code Description Scope Message for Exclude

HIPREPL

Hip Replacement

Claim

EXCLU-001

Episode Criteria

Type In/Not In Procedure Group In/ Not in Diagnosis Group Match on Category

Trigger

In

(3340, 3341, 3342)

-

-

-

-

Include

In

(2201, 2202, 2203, 2204)

-

-

-

-

Exclude

In

(2794, 2795)

-

-

-

-

A bundled amount is configured as a lump sum:

Bundled Amount

Code

Description

Episode Definition

Priced on

Categories

HIPR-LUMP

Lump Sum for Hip Replacement

HIPREPL

Triggering

-

Provider pricing clauses are configured for different hospitals, possibly paying different amounts:

Provider Pricing Clause

Provider Reimbursement Method Amount

St. John’s

HIPR-LUMP

$ 60000

St. Mary’s

HIPR-LUMP

$ 70000

The following claim is processed:

Claim 1

Line Provider Serviced Person Procedure Episode? Type Allowed Amount Message

1

St. John’s

John Doe

2794

N

-

-

EXCLU-001

2

St. John’s

John Doe

3340

N

-

-

3

St. John’s

John Doe

5521

N

-

-

Result

  • Claim line 2 would be identified as trigger, but claim line 1 acts as showstopper, preventing any claim line in the claim from being recognized as part of the episode. Scope 'Claim Line' would lead to the same outcome.

Scenario 4 (Pricing per Category)

The configuration below illustrates the usage of categories to split the pricing into different parts:

Episode Definition

Code Description Scope

HIPREPL

Hip Replacement

Claim Line

Episode Criteria

Type In/Not In Procedure Group In/ Not in Diagnosis Group Match on Category

Trigger

In

(3340, 3341, 3342)

-

-

-

SURGERY

Include

In

(2201, 2202)

-

-

-

PREOP

Include

In

(2203, 2204)

-

-

-

POSTOP

Bundled amounts are split into categories:

Bundled Amount

Code Description Episode Definition Priced on Categories

HIPR-LUMP

Lump Sum for Hip Replacement

HIPREPL

Triggering

-

HIPR-LUMP-SURG

Lump Sum for Hip Replacement Surgery

HIPREPL

First

SURGERY

HIPR-LUMP-PREOP

Lump Sum for Hip Replacement PreOp

HIPREPL

First

PREOP

HIPR-LUMP-POSTOP

Lump Sum for Hip Replacement PostOp

HIPREPL

First

POSTOP

Provider pricing clauses are configured depending on the hospital:

  • for St. John’s, a lump sum pricing is configured

  • for St. Mary’s, pricing per category is configured

Provider Pricing Clause

Provider Reimbursement Method Amount

St. John’s

HIPR-LUMP

$ 60000

St. Mary’s

HIPR-LUMP-PREOP

$ 10000

St. Mary’s

HIPR-LUMP-SURG

$ 50000

St. Mary’s

HIPR-LUMP-POSTOP

$ 8000

The following claims are priced:

Claim 1

Line Provider Serviced Person Procedure Episode? Type Allowed Amount Category

1

St. Mary’s

John Doe

2794

N

-

-

2

St. Mary’s

John Doe

3340

Y

Trigger

$ 50000

SURGERY

3

St. Mary’s

John Doe

5521

N

-

-

Claim 2

Line Provider Serviced Person Procedure Episode? Type Allowed Amount Category

1

St. Mary’s

John Doe

1021

N

-

-

2

St. Mary’s

John Doe

2204

Y

Include

$ 8000

POSTOP

3

St. Mary’s

John Doe

2203

Y

Include

$ 0

POSTOP

Result

  • Claim line 2 in the second claim is the first of category POSTOP so gets the price.