Managed Care Contracting & Provider Payment

CO-OP Primer Article is Published

Here is an article that I wrote with Leah Stewart of Beatty, Bangle & Strama, PC of Austin, Texas.  It was published by the American Bar Association's Health Lawyer, so has an understandably legal slant.  It gives an overview of the Consumer Operated and Oriented Health Plan Program to date.  Since then, I've been up to my ears with filing applications on behalf of CO-OPs and working to get them formed.

Anyhow, for your reading pleasure:  The Health Lawyer Article

Robert Wood Johnson Article on CO-OPs

As regular readers know, I have been working on developing Health Care Cooperatives (called "Consumer Operated and Oriented Plans" or "CO-OPs") under a program created by the federal health care reform law.  The Robert Wood Johnson Foundation recently published an article by Bradford H. Gray, PhD. giving an overview and early assessment of the CO-OP Program.  The article can be found HERE.

I hope you'll find it interesting.

Revised Claim Rules offer Claimants New Opportunities to Trip Up

Several months ago, I posted an article describing the new federal minimum claim standards, including the availability of external appeals.  These new standards were included in the PPACA and published as an interim final rule on July 23, 2010 (the "Interim Rule").  At the time, I referred to these rules as enhancing an important set of rights for enrollees and for providers assisting their patients with coverage disputes.  For a more complete list of the changes required by the PPACA, see that earlier post, see link here.

On June 24^th, 2011, amendments to the Interim Rule were published by HHS, the Department of Labor and the Treasury (the “Amendments”).  These Amendments incorporate public comments received in the wake of the Interim Rule.  Unfortunately they weaken claimant rights and delay or undermine many of the measures intended to simplify the appeal process.  The changes affect expedited coverage determinations, the information included in notices of coverage determinations, rights to external appeal and the procedures governing external appeal.

CO-OP Proposed Rule Is Posted

On Monday, HHS issued its set of proposed rules for the Consumer Operated and Oriented Plan Program.  I wrote about it earlier here and that article provides the context for the cryptic notes that follow.   These same proposals appear in this morning’s Federal Register.  Although I am still going through the rule, some initial notes:

Guest Post: National Healthcare Decisions Day

Because April 16th is National Healthcare Decisions Day, I am posting the following guest post, written by Nathan Kottkamp:

New Model Law Requires Cost Estimates & Disclosure of Facility Based Provider Balance Billing

On March 6, 2011, the National Conference of Insurance Legislators (“NCOIL”) finalized model legislation intended to provide consumers with information about balance billing practices of facility-based providers.  More significantly, the law would require health plans to provide enrollees with information about out-of-pocket costs of elective procedures.  The law, if adopted by any state will impose requirements on facilities, facility-based providers and health benefit plans (including health insurers, managed care plans, multiple employer welfare arrangements, an entity that direct-contracts with providers on a risk-sharing basis) to inform patients about balance billing practices by facility-based providers who are out-of-network  with the patient’s health plan.

Old Forgotten Contracts … A Cautionary Tale

Once upon a time, several practitioners formed a group.  The group signed a contract to receive referrals from a network.  The group never did receive referrals from the network.  One day the group split up and one particular practitioner continued practicing alone. 

ACO Rules out tomorrow?

http://www.politico.com/news/stories/0311/52170.html

COOPs: A Little Known Provision of the Health Reform Law

There is a provision of the Patient Protection and Affordable Care Act (the “ACA”) that seems to be a “sleeper” in the news, but it could have a very large impact on the market for health insurance.  The provision, Section 1322 of the ACA, requires the federal government to provide start up funding for “non profit, member-run health insurance issuers”. 

Some Thoughts About Financial Hardship Waivers

Providers have maintained financial hardship policies for decades.  Typically, a provider establishes a process for determining which patients qualify for its charity care program.  What’s new about this?

This process used to be primarily for uninsured patients.  However, in light of the increased enrollment in high deductible health plans and reductions in insurance benefits (i.e., capped and limited services, increased co-payments), more and more underinsured patients are asking for financial hardship waivers.  See earlier posts on HDHP and Underinsurance HERE and HERE.  What had been a process exclusively between patient and provider now can have ramifications with the payor.  Can you grant a patient’s request for a hardship waiver without jeopardizing your payment from the insurer or self insured payor?