To see a sample treatment plan, click here. (It is suggested you print out the treatment plan for immediate reference .)
On the last line of the upper right-hand section, the plan reports the patient's diagnosis; in fact, it can show up to three diagnoses and their corresponding probabilities. The code number for the first diagnosis is 996.01; this is the diagnostic code (an ICD-9 code) for a pacemaker malfunction. A probability of .95 is also reported, indicating that the Diagnostician feels there is only a 5% chance that his diagnosis is incorrect. The multiple diagnoses and their corresponding probabilities indicate to downstream doctors the degree of confidence that the Diagnostician has in his primary diagnosis and other diagnoses he considers as possibilities.
The treatment plan shows several tests that the Diagnostician has performed or ordered (and their Current Procedural Terminology [CPT-4] codes)—an EKG (93000), a chest X-ray (71010), and a pacemaker analysis (93734). These are all diagnostic tests, the costs of which are included in the small copayment that the patient makes to see the Diagnostician. The Diagnostician has also determined that the patient requires two specific treatments that are to be conducted by another doctor: a Swan-Ganz Line (93503) and insertion of a permanent pacemaker (33206). These last two treatments are to be performed at the same time, and a follow-up visit is needed, so the treatment plan includes three (intermediate) office visits (90060), including the current visit.
Each scheduled procedure also has an expiration date; this is to encourage the patient to have the procedure performed before his condition worsens and requires more costly treatment. If a patient fails to obtain a treatment before the expiration date, then the treatment must be reauthorized by the Diagnostician. To discourage lateness, the patient is charged a nominal rescheduling fee. Such a fee is easily justified not only by the effort required to reschedule a procedure, but more importantly by the possibility of health degradation and higher treatment costs that the patient has caused by his delay.
The last column in the treatment plan shows the benefit amount for the treatment. There are also columns for the date of the treatment and the amount charged; this information is entered by the downstream doctor after the treatment has been performed.
The treatment plan shows a charge of $50.00 and a benefit of $40.00 for the patient's office visit with the Diagnostician. The implied $10 copayment is charged to the patient whenever a new treatment plan is prepared. No copayment is required on a continuing treatment plan, since the patient should not be discouraged from receiving medical treatments that have already been prescribed by the Diagnostician. Except for this small copayment, the cost of in-office diagnostic tests and tests obtained from outside suppliers, including imaging, are paid directly by the insurer. The payment structure within this part of the RE·MEDI system is similar to that of an HMO.
The $10 copayment, besides defraying a small share of the cost of the Diagnostician, acts as a deterrent against abuse. The copayment is one of two hurdles that the patient must pass before having the opportunity to receive Reference Pricing + Rebates payments. The second hurdle is more difficult to surmount, even though it costs the patient nothing: it is the certification by the Diagnostician that the patient's condition is sufficiently serious to require additional treatment from a downstream doctor.
The treatment plan also shows any drugs that are prescribed for the patient. In the present example, the drug is Blocadren, to be taken twice a day (2D). The prescription consists of 75 pills of 10 milligrams each (10mg/p); three refills of the prescription are allowed. We see that the benefit amount is $65.25 per prescription.