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Encompass

July 11, 2022 by Anny Shechtman,

Value-Based Reimbursement Solution

Encompass

Encompass helps you easily bundle payments to improve care and cost outcomes. This value-based reimbursement solution uses our proprietary pricing technology to apply a reference-based price to a clinically predefined, medically accepted Episode of Care so you can focus on value-driven outcomes, not the amount of care delivered.

These days, a single procedure is anything but singular: even the most straightforward care delivery requires numerous providers and services, including the physician and anesthesiologist, medical equipment, the hospital, post-treatment care, and more. Bundled payments were introduced to untangle this billing confusion to improve the value and quality of care received. Also referred to as value-based payments, bundled payments make it possible for payers to provide one reimbursement payment for one comprehensive claim to all involved healthcare providers.

Encompass offers a flexible, efficient alternative to the traditional fee-for-service model. By creating a new path for pricing transparency and plan sustainability, our offering encourages providers to focus on value-driven outcomes, not the amount of care they deliver. The benefits of the Payer Compass value-based solution extend into your population health and case management programs, helping to identify care variations, reduce readmits, and identify over/under use that further supports successful employee healthcare benefits.

  • One bundle, one bill
  • 90+ uniquely defined Episodes of Care
  • 10 – 12% bundled payment savings compared to fee-for-service
  • 300% enrollment growth in the Value-Based Medicare Advantage Model

What Makes Encompass Different from other Reimbursement Solutions?

  1. Can add on to existing bundles or custom-build from scratch
    a. Build, analyze, and price bundles
    b. Custom-built from ground zero or as an extension of existing bundle
    c. Bundles / Contracts transition easily from analytics to operationalized pricing
  2. bundled payments and capabilities
    a. 2018: 50% of Medicare payments based on quality and value vs. 2016: 30% of Medicare payments based on quality and value
    b. Public/Private Bundle Analytics
    c. Benchmark Fee for Service
    d. Benchmark against Government Reimbursement (FFS)
    e. Revenue-Neutral Contract Models
    f. Bundling in light of termination, risk factors, etc.
    g. Comprehensive data model facilitates a seamless transition from analytics to operations
  3. delivery of care
    a. All services and equipment are bundled into one bill using a defined Episode of Care.
  4. next-gen pricing
    a. A reference price is applied to the EOC bundle using a Medicare-based rate.
  5. transparency delivered
    a. The payer receives the repriced bundle that reflects applied pricing and edit logic.
  6. value rewarded
    a. One reimbursement payment is made across all providers by the payer
  7. retrospective bundling
    a. Compare actual costs to predetermined amounts to focus on reimbursement accuracy and shared savings.
  8. Uses an API or an EDI workflow
    a. With the API workflow, the health plan or TPA is on the front end of the claim process. Claims initially come into the claim adjudication system and are submitted to Payer Compass for real-time processing.
    b. With the optional EDI workflow, Payer Compass is on the front end of the claim process. Claims received by the clearinghouse are routed to Payer Compass for pricing and editing. Claims are returned to the clearinghouse before being routed to the payer. Additional content, i.e. contract and Process Trail information can be accessed via web -service.

How does Encompass work to improve price transparency?

We can help clients identify opportunities within bundles payment strategies. This is done by first identifying possible high-cost episodes, revenue risks, revenue opportunities, and financial risks. We then look at what can be done to mitigate high costs and poor care through tools like prospective and retrospective pricing. After those initial steps, we proceed to monitor the outcomes through continuous cost and volume trends and readmission.

Identify Identify

Respond Respond

Monitor Execute

Episodes of Care within Encompass

Encompass, a value-based solution, helps you bundle payments to improve care and cost outcomes. Encompass uses our proprietary pricing technology to apply a reference-based price to a clinically predefined, medically accepted Episode of Care. Each Episode includes everything that’s needed for the named service or procedure. Our pivotal solution defines more than 90 different Episodes of Care in 12 categories, covering the most common procedures.

Here are some examples of episodes of care covered within Encompass:

  1. Government reimbursement Market
    1. Medicare
    2. Medicaid
    3. CJR
    4. Cardiac EPM
  2. Commercial Reimbursement Market
    1. Extensive customizations
  3. Private Bundling Programs
    1. Flexible bundling management
    2. Risk stratification
  4. Public Bundling programs