在医疗保险医生费用表中量化间接收费
John F Mulcahy1, Sadiq Y Patel2,3, Ateev Mehrotra4
1Division of Health Policy and Management, University of Minnesota School of Public Health, Minneapolis.
JAMA health forum
|April 11, 2025
概括
预先实践的临床医生 (APC) 在2022年间接提供了38.9%的医疗保险办公室访问. 直接的APC计费可以每年为医疗保险节省2.7亿美元,提高患者护理交付的透明度.
科学领域:
- 医疗保健服务研究 医疗服务研究
- 医学经济学 医学经济学
- 临床实践管理的管理.
背景情况:
- 先进实践临床医生 (APC),包括医生助理和护士从业人员,可以直接或间接地向医疗保险收费.
- 间接计费,通常称为"事件"计费,涉及以医生的名义提交索赔,可能导致更高的报销.
- 了解间接APC计费的数量和财务影响对于医疗保健政策和实践至关重要.
研究的目的:
- 量化医疗保险计划中APC间接收费的办公室会议的数量和支出.
- 区分APC提供的服务的直接和间接计费做法.
主要方法:
- 一项使用医疗保险服务费和医疗保险优势索赔数据的队列研究,从2022年开始.
- 将医疗保险B部分 (医生/临床医生服务) 索赔与D部分 (处方药) 索赔联系起来,以确定处方临床医生的唯一标识符.
- 通过分析与临床医生标识符相关的处方药填充数据来区分间接收费的APC服务.
主要成果:
- 在2022年,通过APC提供的38.9%的办公场合被间接收费.
- 对于中位数的医生来说,APC服务的间接计费占他们总计费用的11.1%.
- 对APC服务的间接计费在外科专家中最为普遍 (29.7%),在初级保健中最不常见 (3.9%).
- 潜在的医疗保险在2022年节省2.7亿美元,如果所有间接收费的APC护理都是直接收费的.
结论:
- 医疗保险公司为医疗保险受益人提供了大量的办公室护理.
- 准确识别间接收费的APC服务对于全面了解医疗保险患者的医疗保健服务至关重要.
- 转向直接的APC计费可以为医疗保险带来巨大的财务节省.
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