Managed Care Up-dates from Trish Peters of Excellentia Advisory Group
More News & Updates to Managed Care Questions August 4, 2010

in this issue

From the Desk of Trish Peters

Forum Questions & Answers #1

Forum Questions & Answers #2

Don't Miss My August 18 Managed Care Forum


 

From the Desk of Trish Peters
Trish Peters

REMINDER
This is the fourth 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

  • Texas Battles Health Law Even As It Follows It
  • There are more uninsured residents of Texas-6.1 million and counting-than there are people in 33 states. The state's elected officials might be expected, therefore, to cheer a federal health care law that is likely to deliver billions of dollars from Washington to Austin and cover millions of low-income Texans (The New York Times).
  • Aetna Posts Higher 2Q Profit Up 42%
  • Health insurer Aetna Inc. said last week its second-quarter profit rose 42 percent, as the percentage of premiums the company spent on medical care fell versus a year ago (The Associated Press).
  • 2010 EquiTrend Study
  • According to the 2010 EquiTrend study, conducted online by global market research firm Harris Interactive, consumers ranked the top six overall health insurance brands as:
    1. Blue Cross/Blue Shield Health Insurance
    2. Aetna Health Insurance
    3. United Healthcare Insurance
    4. Kaiser Permanente
    5. Cigna Health Insurance
    6. Humana Health Insurance

  • AHRQ's State Snapshots Report Now Includes Health Insurance Data

  • Reported in Healthcare Finance News: Washington-The Agency for Healthcare Research and Quality has released its annual healthcare state-by-state quality report, which includes new data on health insurance. According to AHRQ officials, the new data on health insurance is categorized by source of payment (including private insurance), Medicare, Medicaid and those without insurance. It allows users to compare payor-specific quality rates as well as differences among payors.
    The 2009 State Snapshots provide state-specific healthcare quality information, including strengths, weaknesses and opportunities for improvement. State-level information used to create the reports is based on data collected for the 2009 National Healthcare Quality Report. As in previous years, the 2009 State Snapshots show that no state does well or poorly on all quality measures, according to the AHRQ. According to the report, Maine, Maryland, Wyoming, South Carolina and the District of Columbia showed the greatest improvement. The five states showing the smallest improvement were North Dakota, Texas, West Virginia, Nebraska and Washington.




    Greetings Doctor, ASC Administrator and/ or Directors!

    Hi, this is Trish Peters, the Director of Managed Care at Excellentia Advisory Group.
    In case you missed our July 28th 30-minute forum, I have enclosed in this newsletter a summary of my answers to the two main questions for that forum.
    I hope that you will mark your calendar and join me on August 18! This is your chance to ask questions and/or get involved in a managed care discussion.
    I also want you to know that I am available to discuss your current managed care contracting needs. Many surgery centers, surgical hospitals and physician practices outsource their contracting needs to me. I have a strong national knowledge of the Third Party Payors and their contracting behaviors.
    Feel free to email at [email protected] as to your need and time availability to talk.


  • Forum Questions & Answers #1
  • Our July 28 Managed Care forum had these two questions that took most of our 30 mintues.

  • I am new to the field (managed care contracting), any information obtained would be greatly appreciated!

  • Since this is something I normally talk about in a one hour webinar and each major topic I discuss in the webinar could really be a webinar in its own, I'm going to cover some very important basics here. Times are tough today, we all know that and during these tough economic times and depending on where you live and your market, it may not be the best time to negotiate with a health plan and expect fantastic rates or expect a rate increase. In some areas plans are tightening down on what and how they will pay providers and are even approaching providers requesting rate reductions! Today it's very important for you to really know who you are, what services you provide, your financial situation and how much your services cost. It's also important for you to know your market and your community. Who is your competition? How do your services differ and is there anything that makes you stand out from your competition? Do you have any unique attributes such as providing specialized or exclusive services? How well known are you in the community? Who are the major employers in your service area and what health insurance do they offer their employees? You can improve your market position by knowing your community, your competition, and providing a service that is unique and increasing your specialization or by providing your services well and going the extra mile. These various factors blend to create the persona of the practice or facility and will provide leverage in your negotiations.
    Whether you're negotiating a new contract or an existing one you always want to operate from a position of strength. Strength comes from two main things. First, information is power. Information is a very successful negotiation technique. As I stated above, information about your practice or facility, the services you provide, your operating costs, your financial situation and how contracts reimburse are vital to your success. The second thing is control the terms of the negotiation by knowing what your deal breaker issues are and the terms that must be changed, what issues and terms must be modified or added and what are the Issues and terms that ideally would be changed or added.
    I also think developing a long term relationship with the plan representative is vital to negotiation success. To build that relationship you must meet with them, show them your practice or facility and show them you're serious about maintaining a mutually beneficial relationship by getting administration and physician leaders involved in your important meetings and key discussions.
    Financial analysis is the final basic key issue I would like to touch on. Contracts must clearly specify the payment rate terms and you must insist on having all necessary attachments and payment policies to properly analyze the rates. Financial analysis should be done on new negotiations, renegotiations and periodically throughout the term of an existing contract. You'd be surprised how many times I've performed a financial analysis on existing contracts for clients and have found areas where the clients were paid incorrectly. In order to do a financial analysis you must know your practice management system and know how to run reports to analyze the rates or verify accuracy. If the financial analysis is for a contract negotiation you can do a rate analysis to model the stages of the negotiation. The rate analysis will allow you to see financially how a contract is doing or will be performing. You should compare or benchmark current reimbursement to proposed and to known standards such as Medicare, Charges or other payors. Good luck on your new position and keep learning!

  • Forum Questions & Answers #2
  • How do I find out my state laws regarding dealing with insurance companies, even such things as waiving co-pays, etc. for plans we are non-par with?

    1. Surf your state Department of Insurance web-site. Search insurance statues, regulations and codes. But if your state web-site is as complicated as Missouri's, there may be a place on the web-site to email your question. This is where I had luck in obtaining the information for Missouri.
    2. Write to the Insurance Commissioner at your state Department of Insurance.
    3. Ask one of your contacts at a managed care plan. The managed care plans have a vested interest in knowing if their state has such regulations regarding the waiving of co-pays. This is how I obtained the Texas statues.
    4. Inquire within your professional organization.
    5. Ask your legal advisor or a healthcare lawyer.

    Plans are getting very creative in the way they are going after and suing out of network groups and facilities who routinely waive co-insurance and deductibles if your state does not have any statues regarding this. The problem is there is a three way dispute involving two contracts but no three way agreement. The plans state the out of network providers hold themselves out as accepting the benefits of their patients' insurance contracts, and often assert a right to payment under those contracts. The physicians are contending that the provider-patient relationship permits them to make any deal they want concerning payment for the provider's services. The insurer-patient relationship is based on a contract with clear rules about what the insurer will pay for and what it will not. But the provider and the insurer have no relationship and no agreement whatsoever.
    This battle will continue until a more definitive solution arrives, whether through a judicial decision, new legislation or regulatory means. The state of New Jersey is currently considering a bill that would criminalize the waiver of co-payments and deductibles for out of network providers. As of last month, it has not been passed. If something like this does get passed, the fear is, it may be adopted elsewhere.
    Bottom line is consult local attorneys to ensure compliance with state laws.

  • Don't Miss My August 18 Managed Care Forum
  • doctor watching webinar newsletter size picture

    My next 30 minute "live" managed care forum is scheduled for Wednesday August 18 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 on QUESTIONS to be taken to a site to enter your forum questions in advance. Trish will prepare a response for presentation at the forum.

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