Our June 16 Managed Care forum had these three questions that took most of our 30 mintues. The answer for #1 and #2 are the same.

1. As a small practice in a competitive area, just starting out we have no leverage in trying to negotiate a higher fee schedule with any of the carriers. The reasons given are-we are not negotiating our fee schedules at this time or it is not in our budget. What are our options besides opting out?
2. What is the best way to negotiate with Medicare and Medicaid managed care companies to get an even slight increase in the contracted rate?

• If your specialists do workers' comp services it could be possible to contract directly with the employers.
• You can also check with your state Medical Society to see if they have any resources available to assist you.
• Another option you can do is join a PHO or an IPA.

3. Do the carriers have a valid legal position to terminate the physician's agreement for using OON facilities? There are clauses in the physician agreements that state physician will make best efforts to utilize in network facilities, but also clauses that state carrier will not interfere with physicians medical decisions.
The main question is, do the carriers have a valid legal position to terminate the agreements? Well, since I'm not a lawyer, I can't answer that, and unfortunately, from state to state, legal and regulatory rules vary widely. I can speak of some of the things I have recently read about in regards to physician termination for using OON facilities. I want to add I have not had any of my clients actually receive the termination letters from the plans although many of them have received the "threat" to terminate letters and I know that throughout the country insurance companies have issued the same "threat" to terminate to physicians who refer to non-par facilities. I'm sure many of you have heard about BCBS of Texas and Horizon BCBS in NJ who have both terminated physicians who were associated with a non-par facility for referring cases to the facility. Insurance companies are also threatening to terminate providers who fail to follow the plan's policies and forms with regard to referrals to non-par providers. In one example, a plan recently implemented a policy stating that although many patients have OON benefits and are free to exercise the benefits, the plan was allegedly concerned patients were not actually making a conscious choice to exercise those benefits. Accordingly, the plan has instituted a rigorous advanced notice policy which requires the referring physician to obtain the patients signature on a specific form prior to scheduling services. In this form, the patient must acknowledge he or she understands the physician or facility is non-par; that the patient can contact the plan to obtain names of other providers who are participating; and that absent special circumstance, the non-par provider cannot waive co-pays and deductibles which is another area plans are using as justification to terminate so, know your state law regarding waiving copays and deductibles. Insurance companies also use other tactics such as capping OON benefits, publishing false or misleading information about the health care provider, ignoring assignment of benefits and making payment directly to the health plan beneficiaries and instituting OON fee schedule tying reimbursement to a percentage of Medicare rates. Again, the rights of the plans to take these steps vary widely from state to state.
Because there may be legal theories available to challenge some of the emerging trends and tactics, many groups and facilities may not have the resources to tackle an insurance company in a litigation battle. Things they can do are to institute class action suits against insurance companies alleging various legal theories. Some physician associations have been active in bringing about state Attorney General investigations into such insurance company practices. Groups and facilities may want to consider contacting local, state and national professional associations to explore lobbying efforts, pooled resources, and judicial intervention options.

MCEG took a poll of health plan executives across the country to discover the top 10 issues impacting their organizations and the industry for 2010. This year the Top Ten is dominated by the role of government, enhancing collaboration and working on affordability. A summary is below. To view full detail of issues go to www.mceg.net:

1. The Role of State and Federal Government in Health Care: Government support, intervention and regulation are having increasing impact on payer's operations, costs and even marketplace strategies.
2. Health Care Reform: Reform legislation will result in dozens of new agencies and grant programs, in addition to adjustments to the insurance market and payment.
3. ICD-10: Changing to ICD-10 will be a significant project across the industry.
4. Data analytics and informatics: Data analytics and information will continue to drive investment in analytics.
5. HIPAA 5010: New HIPAA requirements will present substantial changes in the content of the data submitted with claims.
6. Consumer Response to Health Care Changes: In 2010 we will see a wave of consumers voicing their opinion on product offerings, costs, networks and reform.
7. Health Data Exchanges: Finding the sustainable financial model is a core issue.
8. Automated Member Acquisition and Retention: Health plans are looking to connect directly with potential members.
9. Providing transparency to health plan data and operations: The ability to allow providers and health plans to utilize secure shared-data continues to expand.
10. Collaboration with Providers as a Business Partnership: Prior authorization and utilization reviews are fading and in their place, is a more collaborative model based on real-time eligibility, benefit verification, access, quality, safety, effectiveness and patient centeredness.

My next 30 minute "live" managed care forum is scheduled for Wednesday July 28 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 enter your questions.