Managed Care Contracting & Provider Payment

New Hampshire adopts “HealthFirst” Standard Wellness Program for Small Businesses

This past spring, New Hampshire passed a law creating HealthFirst, a health insurance program offering a standardized set of benefits intended to emphasize wellness.   The law is intended to create an affordable form of health insurance for employers with between 1 and 50 employees.  HealthFirst will focus on wellness and the role of the primary care physician in effectively managing care.  The product, which is designed to launch on October 1, 2009 is said to resemble a product offered in Rhode Island, which has saved small employers 15% of premiums.

Still more on Silent PPO Legislation: Indiana

Continuing the trend of state medical societies to restrict the transfer of physicians’ discounts, Indiana has passed legislation restricting the activities of Silent PPOs. 

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.

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

Asking for Assistance

I am working on an article about Silent PPOs.  Do your state's laws prohibit or restrict Silent PPOs?  Here is a link to an article about them: Silent PPOs  I know about several states and would appreciate additional state law cites.  Thank you!

6 Health Plans Agree to Adopt Physician Ranking Code Promoted by NY Attorney General.

Several state and national insurers have agreed to follow a code for their physician quality ranking efforts. The code is contained in “first in the nation” legislation supported by the NY Attorney General and is announced as a major attempt to coordinate the insurer’s various health care quality transparency initiatives and to provide transparency for the ranking process.

Medicare Won’t Pay Hospitals for “Preventable Errors”

On August 1^st, CMS posted its Final Rule with inpatient hospital payment reforms. In addition to increasing payment an average of 3.5%, and increasing the number of severity-adjusted DRGs, it excludes coverage for 8 “never events” occurring during the  inpatient stay. Described roughly, these are –

California Announces PPO Scorecard

Last week, the California Department of Insurance announced it was implementing the first healthcare report card for preferred provider organization products, according to an LA Times Article.  California is believed to be the first of many states who will eventually measure and make this information public.