ORLANDO--Case rate contracting for reimbursement of stem cell and
bone marrow transplants has many benefits, and these can be maximized
through careful, efficient record keeping, said Jonathan Patten,
manager of contracting at Fred Hutchinson Cancer Research Center,
Seattle. With this payment method, payers and providers negotiate a
flat rate to be paid for each transplant patient.
Speaking at a transplant conference, sponsored by IBC/Infoline, Mr.
Patten outlined the Fred Hutchinson approach to preparing and
tracking case rate contracts for transplant patients.
He first stressed the importance of patient registration. "We
identify transplant patients by the admitting physician," he
said. "You also need to be aware of other contracts that affect
The Center uses a "Contract Status List" form to track
contracts. This form outlines, among other things, the payment terms
of the contract and its expiration date. "I use it to identify
contracts that need to be renegotiated," Mr. Patten said.
"Our billers use it to make sure we are getting reimbursed properly."
The case rate coordinator gives a "Bone Marrow Transplant Global
Patient Card" to both patient and donor (for allogeneic
transplants). The ID card, when presented to providers, clearly
instructs them to bill Hutchinson for all services and includes
Hutchinson works closely with nearby Swedish Hospital, which employs
billers dedicated solely to case rate contracts. "We send some
of our patients to outside physicians, and they send their bills for
the case rate period to Hutchinson, so billing is a complicated
process," Mr. Patten said.
Bills must be bundled accurately and sent to insurance companies with
cover letters spelling out charges and other details. "These
dedicated billers are experts," he said, "and this has
helped us considerably. On the insurers end, of course, you
dont have as much control."
In terms of the process of case rate tracking, as opposed to the
system, Mr. Patten emphasized that "case rates should be based
on fixed dates, not on clinical events. The latter requires the
involvement of clinicians to interpret, and that gets very expensive,
with no benefit to the insurance company or provider."
When patients first enter the Hutch-inson system, they are
interviewed by a patient financial counselor, who provides the
above-mentioned Global ID card. The counselor completes a
"Clearance Form" identifying the person as a transplant
patient, and this is sent to a utilization review nurse who creates a
case rate folder.
"Case Rate Notification" sheets identify the case rate
period and are used by billers to determine whether services were
provided during or outside of that period. These sheets are sent to
the billing department for the hospital and the Centers own
physician group billing department so that bills can be bundled
properly. The case rate coordinator also gets a copy so as to
identify the outsider provider bills for the case rate period.
This clinical coordinator (who is either a physician or nurse) fills
out a "Schedule of Treatment" form with key clinical
information on the patient.
Collecting the Bills
As the case rate period progresses, all bills from Hutchinson, the
patients physicians, and all outside providers are sent to the
case rate coordinator, who packages bills with charges broken out and
sends them to the patients insurers.
Hutchinson has a trademarked automated "ClaimPay" computer
system, with payer, provider, and patient entry screens. This system
identifies services that occur within the case rate period and
generates remittances for both payer and provider.
Mr. Patten attributes Hutchinsons successful modeling of
contracts to its information-gathering process. "All our
transplant patients are involved in clinical research, so we have a
large database of information in addition to the various billing
databases. I include all patients to get the large sampling I need to
set reimbursement rates. With the computerized database, I can list
all patients, services, and charges both inside and outside of the
case rate period."
Contracts are monitored quarterly, he said, with high-cost cases
flagged and scrutinized to see why the charges were high, if they
were avoidable, and if there was a high number of inpatient days.
"Take advantage of the benefits of case rate contracting,"
Mr. Patten said, "but dont take on any more risk than
necessary." He advised institutions to "insist on stop/loss
or outlier clauses, and include termination language you can live
with." In other words, regard the contract as a long-term
relationship, but be prepared to terminate if necessary.
Have a mechanism in place for reviewing high-cost cases, he said, and
capture data in the format that will be the most useful to your institution.
"If the system you need doesnt exist, create it," Mr.
Patten advised. "Dont be afraid to lead the process when
you see a better way to do something. And be sure to avoid surprises.
Raise potentially troublesome issues before contract renegotiations