Can someone help interpret this job posting?

[FormLetter]

I think it sounds fairly interesting, and it is work that at least aims at solving one of the main components of the "health care crisis".

You may get some real entertainment out of seeing the innumeracy of doctors if you get involved in risk-sharing negotiations or at least support them behind the scenes.

[Rex Ryan]

Originally Posted by Falco

One other question. Does this sound like something interesting? Like something you would want to do if you couldn't have an actuarial job? Not that I have given up on that.

If a job pays the bills it is a good job. In general, work being interesting is more about the people than the job. If you like the people and the culture it will be fun. If not, the work won't be.

Such was the case in school and also in work life. It was less about the subject than the teacher. A good teacher or good boss makes all the difference.

[Klaymen]

I have a decent boss and my current position, but there isn't any people anything. And I can get by on low contact but I did enjoy the high contact at my previous job, to be fair.

But I do feel somewhat underutilized. People I think are reasonably impressed at the stuff I've come up with in the last 3-4 months, but I feel like I could be doing so much more... They were initially going to hire 2 ppl to do all their number crunching and analysis, but only liked me out of the initial candidate pool. Since then the boss has struggled to keep me fully occupied because I devour tasks and also but a lot of good work into them. I'm doing the work of 1.5 - 2 people that would normally make this amount for the price of 1.

[Klaymen]

Originally Posted by Rex Ryan

Reimbursement methodology 1: fee for service, doctor or hospital does service, they get paid a fee, encourages providers to perform lots of services, do a cesarean instead of vag, do back surgery when not called for, etc
Re meth 2: Case rate, if you have a bypass they get paid $x, vag deliv $x, c sect $y.

How are these two different? They sound almost the same?

[Bamafan]

Originally Posted by Falco

How are these two different? They sound almost the same?

Fee for service: the risk of a more complex case falls to the insurer, since the more services performed by the provider, the more paid by the insurer

Case rate: the risk of a more complex case falls to the provider, since the insurer pays the same rate for a given case regardless of the number of services needed to treat the case

[Klaymen]

Originally Posted by Bamafan

Fee for service: the risk of a more complex case falls to the insurer, since the more services performed by the provider, the more paid by the insurer

Case rate: the risk of a more complex case falls to the provider, since the insurer pays the same rate for a given case regardless of the number of services needed to treat the case

Thanks that makes sense.

[Rex Ryan]

Originally Posted by Falco

How are these two different? They sound almost the same?

Case rates usually happen for hospitals. So if you have a bypass surgery they pay $30,000 and it doesn't matter how many band aids they use or $10 aspirin they give you and it doesn't matter if you spend 3 days or 5 days in the hospital. Hospitals sometimes get per diems, like $5000 per day.

OBgyn doctors get a case rate for delivering a baby, so it doesn't really matter if they see you once a week or once a month during the pregnancy. If it were FFS they might have you come in every day for an office visit I guess.

Also in the FFS world they can sometimes upcode things like an office visit becomes longer or more complicated. Or they double code for things. Like they did a toe surgery on one toe and then did another surgery on another toe and then they stitched up their incisions when all the procedures should be covered by one code. With case rate, they would just be paid based on the diagnosis and not how many tests they do. (Sometime there are 'carveouts' for things like implants, or high cost drugs and stuff)

[Klaymen]

Thanks for your responses, they helped me to have a very engaging interview. I think I did very well but won't know for a few weeks. I think they were reasonably impressed that I knew what RVU was and they appreciated that most people in this new position are going to have a steep reimbursement learning curve, but I have the technical skills to help sort out their data and process issues.

The interviewers did admit from time to time some of the company's actuaries come to them for information about how things work, and that they are surprisingly friendly. Clearly they have some moles in the company purporting to be actuaries and got it all wrong, since actuaries aren't allowed to have personalities.

[Klaymen]

Originally Posted by FormLetter

I think it sounds fairly interesting, and it is work that at least aims at solving one of the main components of the "health care crisis".

You may get some real entertainment out of seeing the innumeracy of doctors if you get involved in risk-sharing negotiations or at least support them behind the scenes.

Thus far I've gotten entertainment out of watching middle-aged women with healthcare knowledge try to design spreadsheets. Poorly. Falco to the rescue!

[Klaymen]

Thought I'd bump this after six months on the job. I have more familiarity with what's going on. We will be doing a lot of work revising the fee schedules December - March. I've been involved with a lot of downloading data, updating reports, writing reports about conclusions I make, sometimes not unlike some responsibilties I've had in prior actuarial roles.

I sit with co-workers a lot and teach them Excel functions and proper spreadsheet design. I even told the boss I would create an Excel training session. It lasted longer than a 1/2 day and one co-worker was flown in to participate (she visits every 3 months or so). It was tremendously successful and I am continually being asked to help write forumlas, redesign existing procedures, etc.

One project that has dragged on is how to incorporate external data with our existing fee schedule in places where we have no experience or anything else to go on. Do we create a price or not, and if so, how?

It has been a pretty good spot to land for some who is restarting his career. Thanks to everyone who gave me advice and helped me land the job. I doubt I will ever come close to the medical knowledge of my peers, but I have definitely proved my worth when it comes to technical abilities. My boss was wise and knew this was missing from her department, and I am definitely making a big impact.