Managed Care Contracting & Provider Payment

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.

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

2009 Health Savings Accounts Limits Published

The IRS Published its updated limits for High Deductible Health Plans and Health Savings Accounts in 2009:

Annual Contribution Limit (maximum allowable deduction) to Health Savings Account
$  3,000 for individual coverage
$  5,950 for family coverage

Minimum deductible for High Deductible Health Plan:
$  1,150 for individual coverage
$  2,300 for family coverage

Maximum out of pocket spending limit
$  5,800 for individual coverage
$11,600 for family coverage

Link to IRS Revenue Procedure 2008-29

New GAO Report Confirms Failure to Fund Deductibles, Offers Hope

A recent report issued by the General Accounting Office on May 14^th underscores how high deductible health plans (HDHPs) present payment issues for patients and consequently, collection issues for providers. 

"Never Events" list to be added

There is so much going on with the issue of "serious preventable health events" that, rather than waiting for the time to write about each one, I'll add a list to the blog giving a short summary of the development and including a link to either the place I learned of it or, whenever possible, an original source.
Happy Researching!

Blue Cross and Blue Shield of Kansas City

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!

HDHP and Underinsurance

A study, published 4/15/08 by the Kaiser Family Foundation showed that those uninsured whom the proponents of high deductible health plans (“HDHPs”) hoped would buy HDHPs, don’t have the assets necessary to pay the deductible. According to the report-

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.

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.

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.