Who’s Got the Check?

Summary: For the first time, healthcare payers could determine which of a patient’s providers was responsible for payment.

Determining which provider is responsible can sometimes be challenging for Health insurance Payers.  Often, this process is complicated since most payers attribute patients to Primary Care Physicians (PCPs), but patients with chronic or urgent conditions may visit a Specialist Physician more than they visit a PCP. Patients who are on Preferred Provider Organization (PPO) plans can change their preferred providers whenever they prefer.

Most attribution depends on retrospective data, usually from the past 12 months. This makes it difficult for physicians to predict and address patient needs in the year ahead. Patient populations in a hospital are not always assigned to a PCP, so our approach was to define the attribution rules for a physician based on factors such as physician’s specialty and the number of times a patient visited the physician’s office in the past 2 to 3 years.

For more information, please download the case study. 

October 16, 2017