How we help employers

Tertiary Care Network negotiates with physicians, hospitals and ancillary providers to create a network or center of excellence in the treatment of specific conditions, such as transplantation. These negotiated savings are accessed by the employer to reduce the expense in paying for a high cost service if and when it occurs.

The Negotiated Price

The contract administrators for the network have the knowledge, gained from experience in negotiating transplant contracts and administering transplant programs, to structure reimbursement mechanisms for transplant contracts allowing for ease of administration, cost efficiency and predictable risk for contracted Payor’s.

Program reimbursements for the physicians and transplant centers are structured to allow for predicable costs and identification of potential risks in each phase of transplantation. The four phases of the organ transplant process are outlined below. Consideration of the transplant benefits offered by contracted Payors, their reinsurance relationships, and the member’s demographics will provide for even further educated assumptions related to the costs of transplantation.

Organ transplantation costs vary tremendously. The cost of organ transplantation is not based on the costs associated with the actual procedure alone but rather the cost of transplantation including the marginal costs of caring and evaluating a patient. Such costs are best identified and managed within the following four categories. As well, consideration of re-transplantation, death and re-admissions criteria is outlined in network agreements. The four categories include:

• Evaluation and Screening
• Candidacy Period
• Global Transplantation
• Post-Transplantation Care

Evaluation and Screening

Typically referred to as zone one, the evaluation and screening zone start when a new patient is referred to the Center of Excellence program specifically for a transplant evaluation either as inpatient or outpatient. Typically included in this zone is all transplant facility, professional and ancillary charges including diagnostic testing. The zone ends when the patient is United Network for Organ Sharing (UNOS) listed as a transplant candidate and transplant is approved or when patient is determined not to be a candidate. A package pricing structure is the preferred contracting methodology for this zone securing a price to exclude non-transplant related services.

Candidacy Period

The candidacy period starts at registration of the patient as a transplant candidate ending on day prior to the transplantation event. Pricing is typically based on negotiated discounts. This zone includes the facility, professional and ancillary support related to registry and search for donor organ including routine surveillance of the patient while waiting for a donor organ.

Global Transplantation

Global Transplantation includes the costs of the facility, professional, ancillary, and acquisition charges. The transplantation event starts one day prior to transplantation ending at discharge from the hospital following transplant. Organ procurement charges vary depending on regionalized organ procurement organizations causing procurement charges to vary necessitating reimbursement at invoice cost.

Post Transplantation Care

Included with the costs a transplant includes the costs of necessary follow-up care for a defined period of time. This zone begins the day following discharge from the hospital after the transplant event ending anywhere from 3 months to one year. Included in the zone are all transplant related outpatient facility and professional expenses. Laboratory expenses will be dependent upon transplant center protocols and can be subject to inclusion in the zone or exclusion with costs being incurred by the contracted Payor’s laboratory vendor. The contracted Payor’s pharmacy vendor and benefit plan design shall govern outpatient pharmacy expenses. This zone excludes inpatient care.