It is critically important that patient identification is fast and accurate in ACOs and bundled payment programs
For example, in the Bundled Payments for Care Improvement (BPCI) initiative, a patient must be enrolled in Medicare Part A and B, not be enrolled in a Medicare Advantage Plan or have ESRD, and fall into a DRG that the health care organization is ‘at risk’ for. Episode Connect determines which patients are in a bundled payment program by applying complex episode logic.
Two ways to identify patients:
Create user centric processes to identify patients and manually enter those patients into a database that assigns them to a particular program.
Use predictive analytics and software to help target specific individuals or populations based on preliminary diagnosis.
What’s the challenge?
- For Bundled Payment Programs, a patient accretes into the BPCI program based on the DRG assigned during their inpatient stay. Unfortunately, most health care organizations don’t know which patients will code into a specific DRG until late in a patient’s stay, or not until the patient has been discharged! Systems and process are needed to predict the DRG, so patients can be on-boarded and enrolled in a care coordination program.
- For ACOs, an admitted patient must be linked to a registry of assigned beneficiaries, alerting clinicians and administrators who typically deploy unique process for these patients during the inpatient stay.
- For Readmission Reduction programs, patients are also assigned on the basis of a final DRG, which is often not an intuitive link to the services being delivered or the patient’s reason for admission. The DRG assigned is typically the most attractive reimbursement for the mix of patient diagnosis and procedures.
The Episode Connect solution
If produced in a timely fashion, Episode Connect uses Working DRGs coded by a hospital’s Clinical Documentation Improvement (CDI) specialists to identify patients prior to their discharge.
Episode Connect monitors Working and Final DRG accuracy, highlighting for users diagnoses that require documentation improvement.
Episode Connect uses predictive analytical software to provide early assignment of patients to a Working DRG.
Gather diagnosis and procedure codes to group into DRGs.
Monitor real-time behavior of hospital billing and CDI specialists, to refine probabilities of assignment to specific DRGs and predict how they will document and code an inpatient stay.