Brainstorm: Payor Incentives for Reimbursement

Go back to managed care fundamentals by using bundled payments and capitation to shift the risk onto the substance abuse treatment providers that, in essence, order the tests. Specifically: payor reimbursement for rehab should include tox screens, and that component of reimbursement should be based on time-in-treatment and not number-of-screens-medically-necsesary. Rehab providers should then either operate their own labs, or purchase screening services from other labs. The parties will need to get just a little creative on how the screens are purchased. I can easily foresee a lab offering to to sell tox screens to a rehab provider on a capitated basis (i.e. per-patient-per-month fees). There are other pricing structures that would work. Theory is that when the party ordering the test pays for the test, fewer tests are ordered.

For starters, how about a national database where physicians and other providers can log in and see exactly what activity is tied to his or her license and NPI. I bet most doctors would be quite surprised as to what gets billed under their publicly searchable NPI. It could be similar to EFORCSE, the Florida prescription drug database that assists us in tracking patients’ filled prescriptions and limiting doctor shopping. It would require the assistance of insurers to self report what is being ordered under whose NPI, but they are the victims of this fraud and abuse so presumably they would be on board with that. The onus could then be on providers to self-report irregular activity. At present there is absolutely no way for a provider to be aware of this activity. One cannot obtain another person’s social security number online, but physician NPIs are public knowledge- it’s really quite baffling.