Quote:
Originally Posted by blueash
If that is the case, then the amount paid is bumped up per patient. That difference goes to the insurance company who then uses the same bumped up factor to pay the providers.
So if by listing diagnoses where no active intervention or ongoing management exists you get your patient looking sicker (lots more diseases and disorders) the provider ends up making extra because their monthly payment is increased for each patient in the plan.
Now this assumes that TVH is paid a capitated per patient amount from UHC. Alternatively TVH could be providing fee for service and billing UHC for each encounter. I have always believed, but DO NOT KNOW, that this is not how it works.
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I thought that the extra money that goes to the insurance company stays with the insurance company but it is assumed that a person with a high RAF score will have more treatment than a person with a low RAF score. If a person has severe health problems, I expect that they see the doctor more frequently than the average person and that the treatment is more complicated.
I don't see how the provider ends up making extra because their monthly payment is increased for each patient in the plan. If TVH were diagnosing the patient to be in worse health than they were, UHC gets more money per patient, but I don't see how TVH benefits because the patient would not be getting the extra treatment. Unless the codes pay more depending on the RAF score?
For example, if a person in good health sees a doctor for a physical and the doctor gets $100, does the doctor get $150 for giving a physical to a person that is "supposed" to be in poor health?
Does anyone know if TVH gets captivated payments per patient?
For example, does TVH get $500 a month for a healthy person and $1000 a month for a sick person? I thought the monthly payments go to UHC - not to TVH - and UHC does its best to limit the amount of treatment that TVH gives its patients because the money that doesn't go to TVH stays with UHC.
The whole process seems to be a lot more complicated than it should be!