Managed Care Up-dates from Trish Peters of Excellentia Advisory Group
More News & Updates to Managed Care Questions June 2, 2010

in this issue

From the Desk of Trish Peters

Forum Questions & Answers #1

Forum Questions & Answers #2

Study Looks At Seven Largest Health Insurers' Payment And Denial Of Claims

Don't Miss My June 16 Managed Care Forum


 

From the Desk of Trish Peters
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.

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  • Managed Care companies shares
  • Click for managed care company latest stock activity.




    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.


  • Forum Questions & Answers #1
  • 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.

  • Forum Questions & Answers #2
  • 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.

  • Study Looks At Seven Largest Health Insurers' Payment And Denial Of Claims
  • 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".

    Read full article...
  • Don't Miss My June 16 Managed Care Forum
  • doctor watching webinar newsletter size picture

    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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