A Practical Guide to ‘Episodes of Care Clinical Programs’

Ensure patient adherence, high-quality clinical outcomes, and the fiscal health of your integrative health practice

Content Quick Links

Introduction
Episodes of Care Programs for Integrative Health, Functional Medicine, and Lifestyle Medicine Practices
Insurance V. Cash-Based Episodes of Care Programs
Continuity is Key
Designing an Episodes of Care Program for Insurance and Medicare Reimbursement
Designing Episodes of Care Programs with a Capitated Reimbursement Model
Designing a Cash-Based Episodes of Care Program
Approaches to Cash-Based Models
Conditions Most Appropriate for Episodes of Care Programs
Delivery of Episodes of Care Programs
[Program Example] Episodes of Care for Heart Disease
Tracking Data and Outcomes for an Episodes of Care Cardiac Program (example)
Increasing Patient Adherence with Episodes of Care Programs
Duration and Pricing Episodes of Care Programs
Legal Considerations When Designing Episodes of Care Programs
Utilization of HSA, MSA and FSA Accounts for Episodes of Care Programs
Conclusion: The Future Signals More Episodes of Care Programs

Introduction

This guide is intended to provide value while you explore the potential benefits of episodes of care programs as it relates to your unique practice, medical center, or hospital.

Episodes of care programs refer to a specific period during which a patient receives clinical and educational services and support for a particular health condition or illness.

These programs utilize a patient-centered, collaborative approach, and incorporate a range of clinical interventions that may include diagnostic tests, medical treatments, medication management, lifestyle modifications, supplementation, health coaching, education, and follow-up care.

For providers of integrative health—the umbrella comprising those who deliver lifestyle, integrative, and functional medicine, and including those experts who practice across a range of specialties—an episodes of care program, and associated business model on which the program is based, can be fully viable for patients and practices.

The goal of episodes of care programs is to provide comprehensive, high-quality care that addresses the patient’s unique needs and helps them achieve optimal health outcomes.

By focusing on episodes of care programs, healthcare providers can improve the efficiency and effectiveness of care delivery, enhance patient satisfaction, and increase engagement. There is also a significant opportunity to reduce long-term healthcare costs by resolving various conditions through the continuity of such comprehensive programs.

Programs may be designed to address specific conditions or diseases such as diabetes, heart disease, or cancer, or may be more general in nature and focus on overall wellness and preventive care.

Episodes of care programs can be implemented in a variety of healthcare settings, including cash-based clinics, concierge and membership-based practices, and those which accept insurance and Medicare. The approach to program design and implementation will differ depending on the setting.

Fee-for-service, cash-based integrative health and functional medicine clinics, including concierge membership clinics, are often well-suited for implementation as they typically have more payment flexibility. That flexibility is especially relevant to clinics which already allow extra time for a personalized approach to care.

Clinics that accept insurance and/or Medicare may also be able to implement episodes of care programs, although there may be more constraints on the payment models and the specific services offered.

There is even an opportunity for private practices, hospitals, and health systems to develop these programs within a capitated reimbursement model that adheres to the key component of value-based care.

Ultimately, the suitability of such programs for a particular healthcare setting will depend on a range of factors, including:

• the needs of the patient population;
• the resources available to the clinic;
• the regulatory and payment landscape (covered later in this guide).

Episodes of Care Programs for Integrative Health, Functional Medicine, and Lifestyle Medicine Practices

Episodes of care programs are a perfect fit for functional medicine, integrative medicine, and lifestyle medicine practices, as these types of providers focus deeply on a holistic, patient-centered approach to care that takes into account a patient’s unique needs and circumstances. Put simply, these practices focus on the patient host environment—physical and emotional.

These programs share many of the episodes of care principles, as they are designed to provide a more comprehensive, coordinated approach to care delivery that is tailored to the needs of individual patients. They can incorporate a range of services and interventions, including lifestyle modifications, dietary changes, stress management techniques, functional labs to inform well-placed supplementation, and other non-traditional treatments that align with the principles of functional, integrative, and lifestyle medicine.

Insurance V. Cash-Based Episodes of Care Programs

Some insurance plans will cover episodes of care programs provided they are evidence-based and have been shown to be effective in reducing healthcare costs and in improving health outcomes.

However, insurance plans may require prior authorization, and will have specific criteria that must be met before coverage (and reimbursement) is provided. The extent of reimbursement will depend on the patient’s insurance plan, the features of the episodes of care program itself, and medical circumstances.

When it comes to reimbursement through commercial payers and Medicare, the process to obtain approval for episodes of care programs can be involved and lengthy. This is why most episodes of care programs offered by providers and organizations are self-pay or cash-based.

Yet, episodes of care programs can be useful for patients who have high deductibles or copays, or who are seeking care not covered by their insurance plan. The programs fit for those who can claim qualified expenses through an HSA, MSA, and FSA account—a significant economic benefit for most patients.

Cash-based episodes of care programs which provide greater flexibility and control over the care that patients receive include concierge medicine practices, direct primary care practices, and wellness programs that focus on lifestyle interventions and preventive care.

While cash-based episodes of care programs may seem more expensive than insurance-covered programs, they usually provide a high level of value and personalized attention to patients seeking more comprehensive, patient-centered care.

Let’s move on to understand the professional and economic benefits for the practice and participating clinicians. 

Continuity is Key

When a patient commits to a series of interventions and guidance over a period of time and pays for it directly as a ‘bundled program of services’, they’ve got skin in the game. This cost is offset by no longer having to pay fee-for-service (via insurance, Medicare, co-insurance) for each encounter.

They become more committed to what they understand is a potentially life-changing, life-improving programmatic process. Even if their initial medical concern improves, they will tend not to discontinue care because they are paying upfront for programmed ongoing care.

This has been a long-term issue for integrative and functional medicine providers who operate within a fee-for-service, cash-based, ‘a la carte’ encounter model. Typically, the health of patients in this payment category initially improves quickly: they stick to many of the healthy lifestyle factors, take their supplements, then discontinue medical care.

The lack of continuity in care typically results in poorer long-term health outcomes, with many patients returning months later to re-engage. This disrupts the cash flow of the practice, making it more difficult to project revenue and ensure the organization’s fiscal health.

I am not categorically suggesting that commercial insurance and Medicare-covered episodes of care programs should not be considered. I want to bring awareness of the limitations and necessary processes to design and get approval for a Medicare and/or commercial insurance-approved program that will lead to better patient outcomes and deliver sustainable reimbursement to the practice.

Designing an Episodes of Care Program for Insurance and Medicare Reimbursement

The process to get episodes of care programs approved for insurance and Medicare reimbursement is achievable though complex. While the specific process may vary, depending on the insurance company or Medicare program, here is a general overview of the steps involved:

1. Program Development: Design and develop the episodes of care program, ensuring that it meets the criteria for clinical effectiveness, patient outcomes, and cost-efficiency.
2. Evidence Generation: Gather evidence supporting the effectiveness of the program—clinical research studies, outcome data, and real-world evidence—to demonstrate the program’s ability to improve patient outcomes and reduce long-term healthcare costs.
3. Coding and Documentation: Assign appropriate medical codes to the services provided within the program. Accurate coding and documentation are crucial for reimbursement purposes as they ensure proper identification and billing of the services rendered.
4. Reimbursement Analysis: Conduct a comprehensive reimbursement analysis to understand the compensation landscape for episodes of care programs. This analysis should include reviewing the policies, coverage criteria, and payment rates of various insurance companies and Medicare plans.
5. Provider Enrollment: Participating healthcare providers will need to ensure enrollment credentials have been supplied to the insurance companies or Medicare plans. This may involve completing provider enrollment applications, submitting required documentation, and meeting specific requirements set by the payers.
6. Contract Negotiation: If necessary, engage in contract negotiations with insurance companies to establish reimbursement rates, terms, and conditions for the episodes of care program. This may involve discussions regarding payment methodology, exclusions, and other contractual terms.
7. Pre-Authorization and Utilization Management: Depending on the insurance company or Medicare administrative protocol, there may be further requirements regarding pre-authorization for the episodes of care program. This can involve submitting detailed information about the program to the payer for review and approval prior to initiating services.
8. Claims Submission and Reimbursement: Once the program is implemented and services are provided, submit claims to the insurance companies or Medicare program according to their specific billing requirements. Timely and accurate claim submissions are essential.

Note: the process and requirements for insurance and Medicare reimbursement can be complex and may vary. It is advisable to consult with healthcare reimbursement experts, billing and coding specialists, and legal advisors who have expertise in navigating the reimbursement landscape to ensure compliance and optimize reimbursement for episodes of care programs.

Designing Episodes of Care Programs with a Capitated Reimbursement Model

A capitated reimbursement model—a key component of value-based care—can be effective to deliver episodes of care clinical programs. It involves the same process of bundling together all the services and resources necessary to treat a patient throughout the entire care journey, just like a cash- or insurance-based reimbursement model.

However, in a capitated reimbursement model, healthcare providers are paid a fixed amount per patient over a defined period, regardless of the specific services rendered. This model shifts the financial risk from payers to providers, encouraging them to deliver cost-effective, high-quality care.

Here’s how an episodes of care clinical program can support a capitated reimbursement model in value-based care, specific to primary care:

• Comprehensive care management: A focus on managing the entire continuum of care for a specific condition or set of conditions. This includes preventive care, early intervention, chronic disease management, and coordination of specialty care when needed.
• Care coordination and integration: Facilitate collaboration among primary care providers, specialists, and other healthcare professionals involved in a patient’s care. The program emphasizes care coordination and integration, ensuring that all providers are aligned in their approach, and are working toward the common goal of improving patient outcomes, while avoiding unnecessary duplication, reducing fragmented care, and enhancing the overall patient experience.
• Continuity of care: Capitated reimbursement models encourage primary care providers to develop long-term relationships with their patients and to focus on preventive and proactive care. Episodes of care clinical programs align with this goal by promoting continuity of care throughout the entire care journey, from initial assessment to follow-up visits.
• Quality measurement and performance incentives: Value-based care models place a strong emphasis on measuring and rewarding quality outcomes. Episodes of care programs in primary care can incorporate quality measures specific to primary care services—as mentioned earlier—such as preventive screenings, immunizations, and chronic disease management. Providers can be incentivized based on their ability to meet these quality metrics, which helps drive improvements in care delivery and patient outcomes.
• Data-driven decision-making: Episodes of care programs generate a wealth of data related to patient care, utilization patterns, and outcomes. In a value-based primary care model, this data can be leveraged to identify areas for improvement, monitor performance, and guide evidence-based decision-making. Providers can use the insights gained from this data to continually refine their care processes, optimize resource allocation, and deliver more efficient and effective care.

By implementing episodes of care clinical programs in primary care within a capitated reimbursement model, healthcare organizations can foster a patient-centered, coordinated, and cost-effective approach to care delivery, while emphasizing the importance of primary care as a foundation for overall health and wellness.

Designing a Cash-Based Episodes of Care Program  

The steps to consider when designing an episodes of care program outside of insurance and Medicare reimbursement—involving a cash based or self-pay model:

1. Program Development: Define the scope, objectives, and components of the episodes of care program. This includes determining the target patient population, the specific health condition or service to be addressed, and the desired outcomes.
2. Service Package Design: Create a comprehensive package of services which will be provided within the program. This can include an initial evaluation, diagnostic tests, treatment interventions, follow-up consultations, and additional resources.
3. Technology Stack: Identify all necessary technology—hardware, software, integrations, and/or custom programming—required to effectively deliver the episodes of care program via virtual, in-person, or hybrid approaches.
4. Pricing Structure: Establish a pricing structure. Consider the cost of delivering the services, including staff time, overhead expenses, and associated materials or supplies. Set a fair and reasonable price for the value provided to patients.
5. Informed Consent and Financial Agreement: Develop a clear ‘informed consent and financial agreement’ document that outlines the program’s details, including the services provided, fees, payment terms, and any refund or cancellation policies. Ensure that patients understand and agree to the terms before enrolling in the program.
6. Marketing and Patient Education: Promote the episodes of care program through marketing channels that will reach the target audience. Provide educational materials, website content, and other resources to inform potential patients about the benefits and value of the program.
7. Payment Collection and Tracking: Implement a system for payment collection that includes tracking financial transactions. This can involve setting up a secure payment portal, establishing invoicing processes, and keeping accurate records of payments received.
8. Outcome Tracking and Evaluation: Develop mechanisms to track patient outcomes and evaluate the effectiveness of the program. This can include collecting patient-reported outcomes, conducting satisfaction surveys, and analyzing data to assess the program’s impact.
9. Legal and Compliance Considerations: Consult with legal experts to ensure your program’s design is compliant and legally sound. Ensure compliance with relevant laws and regulations, such as patient privacy (HIPAA), advertising and marketing regulations, and any applicable state or local healthcare laws.

Approaches to Cash-Based Models 

Designing episodes of care programs outside of insurance and Medicare reimbursement provides more flexibility in pricing, service offerings, and program structure. However, carefully consider the financial viability, patient affordability, and competitive landscape to ensure the program’s success.

Episodes of care programs can be charged on a cash basis in a variety of ways, depending on the specific program and the needs and preferences of the patients being served. The primary models for charging this way include:

1. Flat Fee: Charge patients a flat fee for the entire episode of care. This covers all the services provided during that period. Carefully design the program based on the anticipated care costs for the condition being treated and include analysis of the severity and complexity of the patient’s condition.
2. Monthly Subscription: Charge patients a subscription fee that covers all the services provided during a month. This approach may be particularly well-suited for chronic conditions that require management and support over an extended period of time.
3. Bundled Services: A bundled services model charges patients for a group of related services that are provided as a package of preventive services or a set of services required for a specific procedure or treatment. This approach may be more convenient and cost-effective for patients who need multiple services.

Note: The specific approach to charging for episodes of care programs on a cash basis will depend on a variety of factors including the condition being treated, the services provided, patient demographics including income and education level, and the needs and preferences of the patients being served.

Healthcare providers and organizations that offer episodes of care programs on a cash basis may also need to consider regulatory and legal requirements related to healthcare pricing and billing.

Conditions Most Appropriate for Episodes of Care Programs

Episodes of care programs can be effective for a wide range of health conditions and diseases. They are particularly effective for conditions that require ongoing, coordinated care, and benefit from a team-based, patient-centered approach:

• Chronic Diseases: Diabetes, heart disease, hypertension, obesity, and chronic obstructive pulmonary disease (COPD) require ongoing management and monitoring. Episodes of care programs can provide coordinated, proactive care that helps to prevent complications and improve quality of life.
• Lyme disease: A complex and multi-systemic condition, Lyme Disease requires a comprehensive and individualized approach to treatment. This might include a range of modalities such as antibiotics, herbal medicines, nutritional supplements, diet and lifestyle modifications, and physical therapies such as massage or acupuncture.
• Autoimmune Diseases: Since there are many types of autoimmune diseases, analysis will determine which are the best fit for an episodes of care program.
• Biotoxin Mold Disorder/CIRS: Those dealing with mold toxicity and resulting chronic inflammatory response syndrome are often challenging, complex patients. Proper testing and treatment can be a lengthy process. Identifying and remediating the environmental mold exposure, should it be in a patient’s home, is critical. Biotoxin Mold Disorder/CIRS lends itself to an episodes of care program model. Adopting the Shoemaker Protocol for such a program should be considered.
• Digestive Health Conditions: Irritable bowel disease, ulcerative colitis, and irritable bowel syndrome are among conditions for which effective treatment with a holistic approach can take several months or longer. Program features may include medication management, dietary modifications, nutritional supplements, lifestyle changes, and ongoing education, including reading food labels and learning which foods are the best for a particular digestive health condition.
• Cancer: Within an oncology practice utilizing anticancer agents, or in a practice supporting those living with cancer through supportive services utilizing integrative oncology—lifestyle factors, education, and supplementation—there are viable options for an episodes of care program to address the population served. Cancer treatment often involves multiple interventions and follow-up care, and episodes of care programs can provide a comprehensive approach to cancer care that includes diagnostic testing, treatment planning, and supportive care such as pain management and counseling.
• Mental Health and Substance Use Disorders: These situations often require ongoing treatment and support, and require a range of services including medication management, therapy, lifestyle counseling, and support groups.
• Behavioral Health: Depression or anxiety are two of a number of situations which benefit patients by providing access to mental health services and support. This can ensure patients receive ongoing care and monitoring to manage their condition effectively, and can include lifestyle behavioral counseling.
• Neurological Health: Dementia management and reversal (for early onset disease) can be an excellent fit. Focusing on core lifestyle factors, cognition exercises, and ongoing social stimulation, activity programs and ‘day camps’ should be considered. See: Dale Bredesen’s ReCODE to adopt into an episodes of care program.

Delivery of Episodes of Care Programs

Provided in a variety of ways, including in-person, virtual, or a hybrid combination, specifics will depend on the type of program, the healthcare provider (and their credentialing and specialty), and the patient’s individual needs, preferences, and limitations.

In-person episodes of care programs typically involve patients visiting a clinic for assessments, diagnostic testing, and treatments. This may include regular check-ups, medication management, blood draws, physical therapy, group visits, and interventions that require hands-on care.

Virtual episodes of care programs use technology to deliver care remotely: telehealth visits, virtual group visits, remote monitoring, and digital health tools that allow patients to track their symptoms, medications, and health metrics from home. Virtual programs can be particularly effective for patients who live in remote areas or who have difficulty with transport.

Hybrid episodes of care programs combine elements of in-person and virtual care, providing patients with the best of both worlds. Patients may receive initial assessments and diagnostic testing in-person, and then receive follow-up care through virtual clinical visits, health coaching, and remote monitoring. This helps reduce the need for in-person visits while still providing patients with the personalized care they need.

[Program Example] Episodes of Care for Heart Disease

Title: Abacus Functional Medicine’s Heart Disease Reversal Boot Camp®

Goals:

• Provide patients with comprehensive, patient-empowered care to prevent complications, improve quality of life, and reverse heart disease.
• Educate participants on the key lifestyle factors to take personal control of their cardiac health.
• Enhance patient satisfaction and engagement by providing personalized, coordinated care.
• Reduce healthcare costs by proactively managing patients’ health and preventing hospital readmissions.
• Effectively track and capture outcomes data and specific endpoints and publish findings in the medical literature.

Components:

1. In-Person Assessments: Patients will receive regular assessments from a multidisciplinary team that includes a cardiologist, nurse practitioner, registered dietitian, physical therapist, and exercise physiologist. Assessments include a comprehensive medical history, physical examination, and diagnostic testing (such as echocardiograms, stress tests, and blood tests) to monitor patients’ heart health and identify any changes or concerns.
2. Medication Management: Patients receive ongoing medication management from a pharmacist and physician, with a focus on optimizing medication regimens to reduce the risk of complications and improve quality of life. This may include medication adjustments, education on medication adherence, and medication reconciliation to ensure patients are taking their medications as prescribed.
3. Lifestyle Interventions: Patients receive counseling from a registered dietitian and physical therapist to help them make healthy lifestyle changes to improve their heart health. For example: guidance on healthy eating habits, support to participate in exercise programs, and participation in stress management techniques.
4. Remote Monitoring: Patients will be provided with digital health tools (such as blood pressure monitors, weight scales, and heart rate monitors) to track their symptoms and health metrics from home. This allows the healthcare team to monitor patients’ health remotely, identify any changes or concerns, and adjust care plans as needed.
5. Care Coordination: The multidisciplinary team will work closely with patients and their primary care providers to ensure that care is coordinated and personalized to meet the unique needs of each patient.

Tracking Data and Outcomes for an Episodes of Care Cardiac Program (example)

A variety of metrics and tools can be utilized to evaluate the effectiveness of an episodes of care program, and to ensure that patients are achieving their desired health outcomes:

• Clinical Metrics: Clinical metrics are used to track patients’ health outcomes and monitor disease progression. These may include measures such as blood pressure, blood glucose levels, cholesterol levels, and body mass index (BMI). Patients’ progress is regularly assessed against these metrics to determine if their health is improving, staying the same, or worsening.

• Patient-Reported Outcomes: Patient-reported outcomes (PROs) are used to gather information directly from patients about their health status, quality of life, and satisfaction with the care they are receiving. PROs may include standardized surveys or questionnaires for patients to rate their symptoms, level of pain, ability to perform daily activities, and overall satisfaction with care.
• Utilization Metrics: Track how often patients are using healthcare services and resources, such as hospital admissions, emergency department visits, and outpatient appointments. By tracking utilization metrics, healthcare providers can identify trends and patterns that may indicate opportunities for improved care coordination or more effective interventions.
• Cost Metrics: Track the costs associated with providing care within an episodes of care program. This may include the cost of medications, diagnostic tests, and other healthcare services, as well as the cost savings associated with reduced hospital admissions or emergency department visits.

By tracking these metrics and using them to evaluate the effectiveness of episodes of care programs, healthcare providers can make data-driven decisions about how to improve care delivery and optimize outcomes for patients.

This same framework, with support from a post-doc biostatistician, will allow Abacus Functional Medicine (AFM) to prepare individual case reports, case series, or additional publications for peer review, publication, and indexing in the medical literature.

By extension, publishing such data on quality program outcomes can be utilized to communicate and effectively market AFM’s evidence-based Heart Disease Reversal Boot Camp®.

Increasing Patient Adherence with Episodes of Care Programs 

Patient adherence to episodes of care program models can be higher, compared to fee-for-service individual appointments, because the design provides a more coordinated and comprehensive approach to care delivery, thus improving patient engagement and adherence to treatment plans.

In a traditional fee-for-service model, patients may receive individual appointments or treatments from multiple providers, with little coordination between them. This can lead to fragmented care, confusion about treatment plans, and a lack of accountability for overall health outcomes. As a result, patients may be less likely to adhere to treatment plans, which can negatively impact their health outcomes.

In contrast, episodes of care programs are designed to provide patients with a seamless, coordinated approach to care delivery, with a focus on achieving specific health outcomes. These programs may include a range of services and interventions—diagnostic tests, treatments, medications, supplements, and follow-up care—delivered within a defined time period.

Because patients are also more likely to understand the purpose of each intervention and how it fits into their overall treatment plan, and feel more accountable for achieving specific health goals, episodes of care programs can help improve patient engagement and adherence to treatment plans, therefore increasing the likelihood of achieving remarkable clinical outcomes. 

Duration and Pricing Episodes of Care Programs

Duration can vary widely depending on the specific program goals, taking into account the condition being treated, the services being provided, and the needs of the patient. In general, the design covers the entire course of care for a particular health condition, from diagnosis through treatment and recovery.

The cost range for cash-based episodes of care programs is dependent on the complexity of care, and costs for coordinated care delivery, which may include a range of services such as diagnostic tests, treatments, medications, supplements, regular health coaching, and follow-up care.

General steps to assist in pricing:

1. Define the scope of your program: Begin by defining the specific services and interventions to be included in your program. This may include diagnostic tests, treatments, medications, supplementation, ongoing educational activities, follow-up care, as well as additional services or support that will be provided to patients.
2. Determine the target patient population: Consider the demographics of the patient population your program will serve—age, gender, household income, level of education, health status, and geography.
3. Estimate the duration of the program: Determine how long your episodes of care program will last, based on the specific needs of the patient population and the scope of the program.
4. Calculate the cost of staffing: Consider the staffing support required to deliver your program, including physicians, nurses, and other healthcare professionals. Estimate the cost of staffing based on the level of support required and the salaries or hourly rates of your staff members.
5. Determine the total cost of the program: Combine the costs of all the services and interventions included in your program—cost of any staffing support, investment in new technology and/or programming—to determine the total cost of the program.
6. Consider pricing strategies: Determine a pricing strategy that makes sense for your program based on factors such as market demand, competition, and profitability goals. You may choose to price your program as a single fee, a series of payments, or a subscription model, depending on your target patient population and the specific needs of your program.

It may be helpful to consult with practice and program modeling experts when developing a pricing strategy that is sustainable and competitive. Pricing your episodes of care program will require careful consideration of the specific services and interventions included in the program, as well as the staffing support required and the needs of the patient population.

Legal Considerations When Designing Episodes of Care Programs

Key areas to consider:

1. Compliance with regulations: Episodes of care programs must comply with federal and state laws and regulations related to healthcare, including those related to patient privacy (such as HIPAA), fraud and abuse (such as the Anti-Kickback Statute and Stark Law), and billing and coding (such as the False Claims Act). It is important to consult with legal and regulatory experts to ensure that your program complies with all relevant laws and regulations.
2. Licensing and credentialing: Providers who participate in episodes of care programs must be licensed and credentialed in accordance with state and federal laws. Ensure all providers involved in your program have the appropriate licenses and credentials, and that they are in good standing with their licensing boards.
3. Informed consent: Patients must provide informed consent before participating in episodes of care programs. This includes informing patients about the nature and scope of the program, as well as any potential risks or benefits. Informed consent should be obtained in writing, and patients should be given the opportunity to ask questions and receive clarification before giving their consent.
4. Liability and malpractice insurance: Providers who participate in episodes of care programs should have adequate liability and malpractice insurance coverage to protect themselves and their patients in the event of an adverse outcome or other legal issue.
5. Data security and privacy: All programs which involve the collection, storage, and sharing of sensitive patient information need to be secure. It is important to implement appropriate data security and privacy measures to protect patient confidentiality and comply with relevant laws and regulations.

Legal considerations are essential when planning episodes of care programs. Consult with legal and regulatory experts to ensure that your program complies with all relevant laws and regulations, and to implement appropriate policies and procedures to protect the safety and privacy of your patients.

Utilization of HSA, MSA and FSA Accounts for Episodes of Care Programs

Episodes of care programs can generally be paid for with Health Savings Accounts (HSAs), Medical Savings Accounts (MSAs), and Flexible Spending Accounts (FSAs) if the services provided within the program are eligible medical expenses according to the guidelines set by the Internal Revenue Service (IRS). HSAs, MSAs, and FSAs are tax-advantaged accounts that allow individuals to save and use funds for qualified healthcare expenses.

When offering an episodes of care program, provide patients with detailed invoices or receipts that clearly outline the services provided and their associated costs. This documentation helps individuals substantiate the expenses and demonstrate that they meet the eligibility criteria for reimbursement from their HSA, MSA, or FSA account.

Conclusion: The Future Signals More Episodes of Care Programs

Episodes of care programs have been gaining popularity as they offer a promising approach to improving the quality and efficiency of healthcare delivery.  This trend is being driven by several factors, including:

• shifting healthcare payment models away from traditional fee-for-service payment models (which incentivize providers to deliver more services without necessarily improving outcomes);
• increased focus on patient-centered care;
• advancements in technology such as telemedicine and electronic health records;
• rising healthcare costs.

This guide has provided a practical overview to further explore the potential benefits of episodes of care programs as it relates to your unique practice, medical center, or hospital. The design and implementation of high-quality episodes of care programs can be complex, but you do not need to go it alone.

FON can develop your vision, and provide end-to-end, turnkey services—or provide a comprehensive roadmap with expert consultative support to guide your team. Schedule a complimentary, 30-minute consultation here.

Photo by bigstockphoto.com/TruePhotography