Managed Care Contracting & Provider Payment

"Insurance Company Rules"

Here is a link to an interesting commercial - I learned about it from Brian King's ERISA law blog.  Yes, it is overblown, but it made me laugh.  Insurance Company Rules  Happy viewing!

AthenaHealth, Inc. a physician practice management company, published its 4th annual payor report card today.  Overall, combining the various measures for:
average days in AR,
% claims resolved on 1st submission,
denial rate,
% charges determined to be patient responsibility,
% claims non compliant with correct coding initiative,
% denial transparency;
% claims requiring medical record submission

I could go into more detail, but you really should see this for yourself.  The report, called Payerview can be accessed here: Link

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.

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. 

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

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:

This morning, the AMA posted the following article further discussing the BCBS Mass. Capitation payment system and, importantly – noting the reactions of some large provider organizations. A link to this article can be found here: AMA News See, especially the last heading How “new capitation” works.

Link to my earlier post about Mass. Blues Capitation Program: here

Link to general discussion of capitation: here

 

Tuesday’s Boston Globe (01/22/08) contained an announcement that Blue Cross of Massachusetts was launching a program to pay "doctors and hospitals a flat sum per patient each year”.

I was reading Steve Lopez’ editorial in the LA Times about the effect on insureds when an insurer changes to its formulary. The editorial focused on the family of a 10 year old boy with cystic fibrosis whose insurer removed his medication from its list of preferred drugs.

This post is more theoretical than my usual writing and I beg your indulgence.

A recent post by Reed Tinsley, a Texas-based CPA, warns about a letter one of his clients received from UnitedHealthcare (“UH”). He quotes the letter as saying "...we are making changes in the way we direct claims payments for services rendered by non-network care providers and facilities. ....UH will pay commercial members directly for services upon receipt of the claim".

The post does not reveal whether these changes are limited to a specific region or benefit plan, including a specific self – insured plan that UHC is administering. It’s likely that the letter from UH doesn’t contain those details, either. This practice is called “refusing assignment”.

Annual Payor Score Card Released

AthenaHealth, Inc. a physician practice management company, published its 4th annual payor report card today.  Overall, combining the various measures for:
average days in AR,
% claims resolved on 1st submission,
denial rate,
% charges determined to be patient responsibility,
% claims non compliant with correct coding initiative,
% denial transparency;
% claims requiring medical record submission

I could go into more detail, but you really should see this for yourself.  The report, called Payerview can be accessed here: Link

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.

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. 

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:

Quick Post: AMA Article on Mass. Blue Cross Plan’s Capitation Payment Program.

This morning, the AMA posted the following article further discussing the BCBS Mass. Capitation payment system and, importantly – noting the reactions of some large provider organizations. A link to this article can be found here: AMA News See, especially the last heading How “new capitation” works.

Link to my earlier post about Mass. Blues Capitation Program: here

Link to general discussion of capitation: here

 

Blue Cross of Massachusetts announces Initiative to Pay Global Capitation

Tuesday’s Boston Globe (01/22/08) contained an announcement that Blue Cross of Massachusetts was launching a program to pay "doctors and hospitals a flat sum per patient each year”.

Dealing with Payor Formulary Changes – a Rant

I was reading Steve Lopez’ editorial in the LA Times about the effect on insureds when an insurer changes to its formulary. The editorial focused on the family of a 10 year old boy with cystic fibrosis whose insurer removed his medication from its list of preferred drugs.

This post is more theoretical than my usual writing and I beg your indulgence.

UnitedHealthCare Refusing to Accept Patient Assignment-of-Benefits?

A recent post by Reed Tinsley, a Texas-based CPA, warns about a letter one of his clients received from UnitedHealthcare (“UH”). He quotes the letter as saying "...we are making changes in the way we direct claims payments for services rendered by non-network care providers and facilities. ....UH will pay commercial members directly for services upon receipt of the claim".

The post does not reveal whether these changes are limited to a specific region or benefit plan, including a specific self – insured plan that UHC is administering. It’s likely that the letter from UH doesn’t contain those details, either. This practice is called “refusing assignment”.