Importance of Out-of-Network for Medicare Direct Contracting Entities

Medicare Direct Contracting Entity (DCE) success is premised on building a coordinated network of providers working towards the same goals of improve health outcomes, improve patient and clinical staff experience and reduce costs under a capitated payment model of total care capitation (TCC) or primary care capitation (PCC).

When exploring options to reduce out-of-network referrals and direct the patient to in-network care-managed services, we found the first step for healthcare clients is to identify the patients at the point of care (in the EHR) and either redirect the care in-network or get involved with the care plan with the out-of-network provider.

With 4-year Medicare health history from claims data, healthcare providers can easily identify such out-of-network encounters and get the details of such encounter in their EHR.

Kris Gates | 480.912.1209 | [email protected]