Payors use a variety of reimbursement methodologies and reimbursement structures. Several reimbursement methodologies might be combined in a single arrangement with a payor, often as a means of transitioning to “value-based” payment. Reimbursement methodologies may include the following:
Effective Jan. 1, 2022, Health Plan commercial members will be protected from balance billing after receiving emergency care and nonemergency care from certain out-of-network providers at in-network facilities. The No Surprises Act, which is included within the Consolidated Appropriations Act of 2021 (the CAA), provides the following:
KPI / Metric Formula or Definition Target Business Purpose Gross Revenue Gross Revenue or “Top Line Revenue” is synonymous with gross charges associated with the provision of services This is…
Carenodes contracts with physicians, facilities and other health care professionals to form our provider networks, which are essential for delivering quality, accessible and cost-effective health care services. In partnership with providers (medical and non-medical, behavioral, primary, substance abuse, and others), we have developed (and are growing) community-wide coalition efforts geared towards addressing larger systemic health, infrastructure or social determinant issues with a large impact on health.
Contract modeling, or analyzing potential scenarios of reimbursements to understand financial outcomes, provides a proactive approach to financial management by analyzing the impact of different elements such as methodologies, rate changes, pricing, payor mix shifts and ever changing regulations on margins, rather than net revenue alone.