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. 

Client

Healthcare

Challenge

Payers need to identify which provider is responsible for a patient in order to measure the quality and the cost of care provided.

Solution

Our team implemented an algorithm to attribute the patient to the hospital’s list of PCPs. For each patient, we counted the number of outpatient office visits within the last 24 to 36 months and then assigned it to the physician with the highest number of office visits.

Benefits

Primary Care Physicians (PCPs) can proactively conduct patient outreach programs. • Primary Care Practice can use the attribution to manage the patient population effectively.

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