Patient Identification

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:

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