Each healthcare provider or facility must manage a set of payment contracts that specify how much will be paid for the care provided by their clinical team. Each contract will bring in a different amount of money for the care provided based on the details discussed between the payer and the provider. This exercise will help you understand the different reimbursement levels when various payment methods are utilized for a set of claims. The information provided in the spreadsheet includes payment methods used for clinic visits, inpatient encounters for acute myocardial infarction (AMI), and physical therapy visits. The amounts or percentages of payment are provided in a contract matrix in the spreadsheet. We are using a simplified contract matrix for this exercise; a realistic contract matrix could include over 100 payers with multiple contract specifications per payer.

Using the attached Excel file, review the Contract Matrix information provided for the three payers listed for inpatient and outpatient services. The contract matrix provides how each payer will pay the facility.

Using the formulas in Excel,

1. calculate the appropriate payment for each encounter for the inpatient, outpatient and physical therapy visits.

2. calculate the total payment received (reimbursement) for the inpatients, outpatients and physical therapy visits.

3. calculate the profit/loss (how much money the facility will make after the received payment) for each for inpatients, outpatients and physical therapy visits.

4. calculate the total profit/loss for each of the payers.

Payer Contract Matrix Inpatient 70% of billed charges for each encounter A Inpatient Encounters for Acute Myocardial infarction (AMI) Payer A Payer B Payer Encounter 1 Days in 4 Hospital Billed $21.000 Charges B $15,00 flat rate for a cardiac case regardless of how much is billed C S8.XIO per day for cardiac cases 3 Encounter Days in Hospital Billed Charges $18.993 S Encounter! Days in Hospital Billed Charges $35,00 Total Reimbursement Total Cost $25,497.62 $ Profit Loss) $25,497.62 $25,497.62 Outpatient Clinic Visit Payer A Payer B Payer Encounter i Billed Charges $375.00 Contract Marx Outpatient Payer Encounter 2 Billed Charges $250.00 A 80% of billed charges for each encounter B $125 for each clinic encounter Encounters Billed Charges $150.00 $150 for each clinic encounter Total Reimbursement Total Cost to Clinic $259.00 $259.XI S259.00 Profi Lass) / Physical Therapy Visit Payer A Payer B Payer Payer Encounter Type Eval Billed Charges Contract Matrix Physical Therapy 65% of billed charges for each encounter $250.00 S8S per Physical Thrapy evaluation B SSO Encounter 2 Type Follow up Billed $125.00 Charges per Physical Therapy Follow up C S8S per Physical Therapy encounter Encounter Type Follow-up Billed $125.00 Charges Total Reimbursement $164.00 $160.OKI S160.00 Total Cost to Clinic Profit/Loss) Lans Total Profil(Less) by Payer