Managed Care Contracting & Provider Payment

"Never Events" list to be added

There is so much going on with the issue of "serious preventable health events" that, rather than waiting for the time to write about each one, I'll add a list to the blog giving a short summary of the development and including a link to either the place I learned of it or, whenever possible, an original source.
Happy Researching!

Resource on Transparency Initiatives

I discovered a web site dealing with transparency initiatives - whether by health plans, states or Medicare.  It is "AboutHealthTransparency".  It appears quite comprehensive and is well organized (where do they find the time?!)  If you're interested in tracking a specific effort at tiering or ratings, it is worth checking out.  Happy researching!

HDHP and Underinsurance

A study, published 4/15/08 by the Kaiser Family Foundation showed that those uninsured whom the proponents of high deductible health plans (“HDHPs”) hoped would buy HDHPs, don’t have the assets necessary to pay the deductible. According to the report-

Another (Questionable) Approach to Transparency

I sometimes participate on a list serve of attorneys who work in managed care - whether from the provider or payor “side of the table”. An attorney representing a group of specialty physicians recently posted asking how he could get information about the rates insurers paid to other area physicians practicing in the same specialty. His suspicion was that his client's insurance contracts were outdated and their payment rates were significantly below the market.

Patient's Charter – A Push for Greater Transparency and Consistency in Physician Evaluations

On April 1^st, a consortium of physician organizations, quality advocates and health plans announced that they had agreed on a set of principles for health plans to adopt to their programs to evaluate and rate physicians. The purpose of the principles was to recognize the need for consistency and standardization in measures.

Potential Remedy for Silent PPO Activity? Court Allows Damages to Georgia Physicians whose Discount Inappropriately Used

Two Georgia physicians sued Private Health Care Systems, a PPO provider network, claiming that PHCS injured them by inappropriately sharing their names and practice information with a company selling medical discount cards to the uninsured (“Capella”). The physicians claimed that their agreements with PHCS limited their participation to those PHCS plans or products whose members had insurance and PHCS misappropriated their identities for commercial gain when it made their names available to Capella for use by Capella card holders.

Improving Up Front Collections – Collecting from Medicare Beneficiaries

This column has frequently discussed steps a provider or practitioner can take to speed up its collection of Member payments. See for example:  

- Maximizing Collection of Deductibles – 10 Thoughts

- Can you Collect that Consumer Directed Health Plan Deductible Up Front?

Can you use prompt pay discounts to encourage payment at the time of service? What if the patient is enrolled in Medicare or Medicaid? Would that violate the prohibition on accepting kick backs? Last month, the Office of the Inspector General issued an Advisory Opinion describing a health system that wanted to offer prompt pay discounts. Although the opinion contains a disclaimer that it cannot be relied on by anyone other than the party for whom it was written, it does offer some guidance. 

Is Your Organization Implementing a Policy for “Never Events”?

I’m once again asking for information from you –

In November, 2006, the National Quality Forum released a list of 28 medical events that it called “serious reportable events.” Shortly after, the Leapfrog Group, an association of employers working to improve health care quality, issued a position statement on what it termed “Never Events”. The Leapfrog Group encouraged hospitals to: (i) apologize to the patient and family affected by the “Never Event”; (ii) report the event to an accrediting reporting agency for medical errors; (iii) analyze the root cause of the error and (iv) waive all costs related to the event.

Quick Post: Los Angeles Establishes Insurance Abuse Reporting Site

We have seen increased state activity taken to investigate health insurers.  Now, the City of Los Angeles city attorneys' office has set up a health insurance industry task force to look into insurer practices that affect patients financially and medically. As part of this task force, last week they launched a web site and invited patients, physicians, hospitals and insurance company employees to report problems with private insurers. The site is www.protectingtheinsured.org. The website states that the site is part of “a law enforcement investigation into potentially unfair business practices by health plans and health insurers, particularly with respect to their improper denial of claims for coverage made by consumers, or their cancellation of consumers’ coverage altogether.”

Link to LA Times Article: Lisa Girion Article

Getting Paid When the Provider is Out-of-Network: How Much, How Soon, What Hassles?

The theme for the latest round of private insurance payment disputes seems to be payment hassles that physicians and other health care providers experience when dealing with private insurers, particularly managed care companies. Here are a few cross references to issues that I hope to cover in greater detail within the next day or so: