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.