Tracking Case Rate Contracts for Stem Cell Transplants

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 patient."

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 contact information.

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 don’t 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 Center’s 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 patient’s 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 Hutchinson’s 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 don’t 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 doesn’t exist, create it," Mr. Patten advised. "Don’t 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 start."