From the Desk of Trish Peters
NEW
This is the second month after I introduced my new
monthly managed care discussion and forum. This is
a "live" webconference and it will only last for 30
minutes. On the 1st and 2nd week of the month, I will
send out an invitation to our audience to request and
query for items of discussion or questions that need to
be answered regarding managed care and
contracting. On the 3rd Wednesday at 12:00pm Noon
Central Time, we will hold a webconference meeting.
This forum will be totally free to attend and will allow
you a chance to get engaged in lively discussions that
are sure to effect how you manage your practice or
ASC.
NEED TO KNOW
- Medicare Cuts Go Into Effect, CMS Holding Off
Claims Processing
The 21.3% Medicare physician fee cut went into effect
on June 1, 2010. CMS has instructed its workers to
hold claims for payment for 10 business days to allow
Senate to act on a bill that would postpone the fee cut
until Jan. 1, 2012 and increase Medicare rates 2.2%
for the rest of 2010 and 1% in 2011.
- Scammers Are Taking Advantage Of Health
Law
WFRV: The Green Bay CBS affiliate is Scammers Are
Taking Advantage Of Health Law
reporting the BBB is putting out an alert about health
insurance related scams. Scammers have been
more active since the health bill passed. As part of the
scam, consumers are being offered bogus insurance
that claims to be part of the new federal regulations.
- Total Medicare Private Health Plan Enrollment,
2000-2010
Mathematica Policy Research reports that Medicare
Advantage Enrollment (HMOs, PSOs, PPOs, PFFS,
etc.) has increased from 6.8 million/17% of Medicare
Beneficiaries in the year 2000 to 11.4 million/24% of
Medicare Beneficiaries in the year 2010.
Click for My June 16 Forum
Survey
Click to Go Directly to June 16 Forum
Registration
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Greetings Doctor, ASC Administrator and/ or Directors!
Hi, this is Trish Peters, the Director of Managed
Care at Excellentia Advisory Group.
If you have attended one of my Managed Care
webinars regarding ASC or physician contracting, you
will find this newsletter issue an important addendum
to the information that you have already received from
me regarding managed care contracting.
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Forum Questions & Answers #1 |
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Our May 19 Managed Care forum had two questions
that took most of our 30 mintues.
1. Out of Network remains a huge
problem with payors restricting members from using
ASCs.
This was really more of a topic of discussion rather
than a question. Because I do contracting all over the
country, I have seen the tactics the plans are using to
restrict members from using out of network facilities.
Here are just a few:
- Threatening to terminate the physician's contract if
they continue to refer to an out of network facility.
- Plans have increase efforts to notify members
when they go out of network and inform them of the
additional costs.
- Separate deductibles for in-network and out-of-
network.
- Limiting the out-of-network benefits.
- Repricing the out-of-network claims to leased
networks in which the facility does participate in.
- Limiting the benefit and pricing information to the
out-of-network provider.
- Assigning the out-of-network payment to the
member.
There are many reasons why an ASC will choose to
not participate with a health plan. Patients have the
right to select where they want to go and in most
cases have paid a higher premium to have that
benefit. Today, more and more physician groups and
facilities are starting to fight back. If you want to strike
back against the plans burdensome protocols or laws
in your state you'll have to gain the support of
legislators and fight for your centers continued
success.
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Forum Questions & Answers #2 |
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What is the best way to monitor drug fee
schedules for an Oncology office that are negotiated
through a PHO.
If the fee schedules are not always adhered to you
must contact the plans and inquire about the
reimbursement discrepancies. Perhaps the fee
schedule the PHO is giving you is out of date since the
plans usually update their fee schedules quarterly.
Ask the plans to notify you when the drug fee
schedules are updated, better yet, try to add language
in the contracts that state the plans must notify you of
any kind of rate change. Watch out for plans that
reimburse on Medicare's ASP methodology because
the plans are usually 60-90 behind CMS. Because of
the delay, it's imperative you are notified by the plans
when the fee schedules are updated. If the plans
won't work with you directly because you are part of a
PHO, insist the PHO provide you with a contract matrix
and request they stay on top of the plans rate
changes. Another thing you can do is limit the ability of
your staff to write off balances over a certain amount
without managerial approval and then review those
claims for contract compliance and discuss the
claims issues with the plans. From the Oncology
offices I have talked to monitoring drug
reimbursement is very difficult, especially when
physicians like to use new and expensive drugs that
have not been classified. Many of the offices use a
contract module or other management tool that
integrates into their claims payments systems to
monitor payments and check for accuracy.
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Study Looks At Seven Largest Health Insurers' Payment And Denial Of Claims |
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Insurers Paying Doctors Faster But Inefficiency
Remains, Especially With Medicaid
From Medical News Today: On May 26, 2010, the
Boston Globe reported that US health insurers are
paying doctors seven days faster, on average, and
denying 12 to 18 percent fewer claims than last year,
but the claims reimbursement system remains
saddled with inefficiency, according to a new ranking
of payers set to be released today. "While most
private insurers have made progress in using
technology to accelerate medical claims processing,
state-run Medicaid programs across the country
continue to lag, the report shows, even as the states
prepare to add tens of millions of newly insured
individuals to their rolls under the national health care
law."
The report, from Athenahealth Inc., "in collaboration
with the Physicians Practice management journal,
drawing on a database of 24,000 health care
providers in 45 states", found that Humana Inc. was
the most efficient insurer. But "the majority of back-
office operations at hospitals, doctors offices, and
insurers remains slow and disorganized because the
fragmentation of the health care industry makes it
difficult to establish standards for technology and
transactions".
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Read full article... |
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Don't Miss My June 16 Managed Care Forum |
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My next 30 minute "live" managed care forum is
scheduled for Wednesday June 16 at 12:00pm
Central time.
I am looking for a couple topics of discussion
beforehand and I will be sure to address those topics
during the forum. We will address all open questions
as time will allow or give my response both in the next
newsletter as well as personal email.
CLICK HERE to present
your forum question.
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CLICK HERE TO FREE REGISTRATION |
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