Managed Care Contracting & Provider Payment

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.

AMA Releases Its Payor Payment Report Card

Following closely on the heels of its recently released Payer Code of Conduct, the AMA has just today released its 2010 National Health Insurer Report Card.  Among the key findings:

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

1st Circuit Upholds New Hampshire Law Banning Disclosure of Physician Prescribing Information

This past November 18^th, the 1^st Circuit overturned a lower Court decision and held that an “innovative” New Hampshire approach aimed at curbing increasing drug prices was not an un Constitutional abridgement of free speech.  The law prevents companies that mine prescription data from selling it to pharmaceutical companies for use by their drug detailers to attempt to influence prescribing patterns. 

Yet Another Form of Transparency: “I know what you paid for health insurance last summer!”

A recently announced draft bill would present yet another form of transparency in the health care marketplace:  disclosure to employees of what the employer pays for their health coverage. It may have some interesting side effects.

New Consumer Rating web site

Here is another consumer rating site to add to the growing list:

"WhereToFindCare.com"  Similar in concept to "Angie's list", this free site is touted as a place where "Anybody can rate [a health care provider] whether they were a patient, caregiver or visitor."

Quick Post: AMA Announces Insurer Rating, AHIP Responds

Yesterday, the Chicago Tribune ran a story describing the AMA's new insurer report card aimed at "hold[ing] health insurance companies accountable for making claims processing more cost effective and transparent and to educate and empower physicians so they are no longer at the mercy of a chaotic payment system that takes countless hours away from patient care."

Link to Chicago Tribune Article: Here
Link to AMA "Cure for Claims" press release: Here

The American Association of Health Insurance Plans has issued a statement noting the improvements in claim payments brought on by electronic claim processing.

AHIP Statement: Here

Price Estimates and Informed Consumers

I received a call from a hospital describing an increasingly common scenario:  a potential patient calls asking for the price of an outpatient CT scan; either because he is uninsured or is covered by insurance with a deductible.  The caller had already called several other providers and this hospital’s price was higher.  Even if the caller was covered by a high deductible plan (and was therefore entitled to pay the insurer’s negotiated rate) the hospital’s charge for the scan was still higher than the competitors’ prices – especially outpatient scanning sites.

The hospital wanted to know whether it could match their “competitor’s” price for the MRI.

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!

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.