Managed Care Contracting & Provider Payment

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.

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. 

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? 

New York Attorney General Reaches Agreement with United HealthCare to Shut Down Ingenix - Aetna also agrees to Discontinue Use of Ingenix

On Tuesday, United HealthCare agreed to the terms of a settlement proposed by the New York Attorney General to end the investigation into the practices if its subsidiary, Ingenix, Inc.  (Link to earlier post about the investigation.)  The settlement, requires United HealthCare to

What is a Network Access Agreement?

I was talking to Marla Durben Hirsch the other day, and she mentioned a warning issued by the California Medical Association to California physicians about a Network Access Agreement.  Apparently this national network is recontracting, so this is an issue that physicians in other states might want to watch. 

Quick Post: Connecticut Passes Law Prohibiting “Silent PPOs”

Connecticut joins approximately 12 other states restricting the selling of a physician’s discount.  The law requires any entity contracting with a physician, group, physician network, IPA organization or PHO to disclose the contracting entity’s intent to sell or lease contract rates, including providing a list of potential “customers” on request.  It requires all ID cards to provide a web address or toll free number access to the discount can be verified at the time of service.  It also requires the contracting entity’s right to sell that discount to terminate when the provider contract ends.   

Thank you to Marla Hirsh for passing this information along!

For a link to the bill, Click Pub. L. 08-126

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.