A model to increase trauma reimbursement in the private practice environment

Trauma physician reimbursement at many trauma centers is based on an academic or employed model. However, private practice is also used, especially at community-based trauma centers. Commercial insurance companies acknowledge that trauma care should be reimbursed at a higher rate than elective practice, but they often lack the ability to separate these lines of business. Federal law also prevents groups that are not integrated from shared negotiation. The objective of this study was to develop a model for private practice billing that provides increased reimbursement for trauma line of business.

The hospital created a trauma contracting organization. This organization contracted with the hospital and insurance companies to deliver trauma care. It obtained fee schedules for trauma care that were greater than for elective surgical care. It then contracted with trauma physicians to deliver trauma care using those fee schedules and its provider number. Data from 2009 were evaluated to determine the impact.

Reimbursement rates were evaluated for multiple carriers and compared between the trauma contracting organization and the standard practice. Rate of reimbursement for self-pay patients and government carriers (Medicare, Medicaid, and Champus) were the same for both: 7% of charges for self-pay and 25% of charges for government carriers. Commercial carriers provided increased reimbursement for the trauma line of business, averaging 7% to 10% more return on charges. The annualized impact was over $300,000 more reimbursement on over $5,000,000 in charges.

This model can provide a means to increase reimbursement for trauma care in a private practice environment.