Question

Which of the following payment models depends on medical necessity for claims reimbursement?

Answer 1

Healthcare reimbursement models are billing systems by which healthcare organizations get paid for the services they provide to patients, whether by insurance payers or patients themselves.

Answer 2

Value Based Reimbursement (VBR) models are intended to encourage healthcare providers to deliver the best care at the lowest cost. VBR takes the best parts of the three traditional reimbursement methods and combines them into an approach that financially rewards doctors for performing better than expected and, in some cases, punishes them for not achieving expectations.

In the simplest form, a payer would estimate how much a population of patients should cost as a target for the providers to achieve. If the average cost per patient is less than the target, the provider gets to share in the savings with the payer – for example, the provider may get 30% of the amount below the target. In a Risk Share, there is the additional element of sharing in the loss – for example, the provider may have to pay back 30% of the amount above the target. Sometimes there are quality metrics that must be met as well, in order to share in prof