Bundled Payments is defined by a hospital admission. It usually includes payment for hospital and all physician services for a specific type of case such as a total hip replacement, coronary bypass surgery, total knee replacement. Some contracts include readmissions within 30 days. (Please refer to Episodes of Care/Global for contracts over longer period of time.)
Since the early 90’s, GADS has administered bundled payment contracts. Until recently, these were referred to as “Global” payments. The first contracts administered by GADS included the Medicare Coronary Artery Bypass bundled payment project, commercial payors, and self-insured employers.
The recent growth of bundled payments is due to a significant effort by Medicare to initiate four models of bundled payments. Of the four models, Model 4 is implemented utilizing a predetermined Part A and Part B payment structure which requires an entity like GADS to assist in the claims administration.
Medicare and Commercial bundled payments are similar:
- Pre-negotiated payment rate
- Identification of patients on admission
- Notification of providers of patient admission
- Claims capture for distribution of payment.
However, the actual process of claims of administration is different. Please see the Medicare and Private Payor tabs for more information. (should you say where the tabs are?)
Common Types of Medicare Bundled Payment Cases (Model 4)
- Orthopedic Hip and Knee Replacements
- Cardiac Procedures
- Spine Procedures
- Congestive Heart Failure
Common Commercial Bundled Payment Cases
- Orthopedic Hip and Knee Replacements
- Cardiac Procedures
- Spine Procedures
- General surgery procedures