Insurance Commissioner Holds Hearing on Network Adequacy

 

  

Last week Insurance Commissioner Dave Jones held a public hearing on issues related to network adequacy with various PPO and insurance plans. One of the concerns being raised with the rollout of Covered California, the California Health Exchange, is that some of the plans offering coverage will do so through more limited provider networks than their traditional private plans. Each participating plan offer different levels of coverage through platinum, gold, silver and bronze packages which basically have a premium level related to the size of the patient coinsurance/deductible/out of pocket maximum, i.e. a lower premium when there are higher copays and deductibles. Many believe that the plan provider rates are going lower and that the provider networks are shrinking because of that.

 

Witnesses from the hospital associations, including specialized facilities like Children's Hospitals, expressed concerns that some of those institutions may not be included in these networks and might threaten the safety net for specialized services. Covered California  has planned  to have a website function that would allow both patients and physicians to determine whether they were included in individual plan networks under their offering. That function had problems when initially implemented and has not yet been restored on their website.

 

Representatives from the ER physicians testified regarding the uniqueness of their position in healthcare delivery that they must treat and stabilize all patients who enter the hospital through the ER. Their ability to participate in some of these networks may be limited both on ability to join and the level of reimbursement. Hospital based radiology groups have some of those same issues. The CRS will be submitting some comments to the Insurance Commissioner.

 


California Endowment Report On Price Transparency Healthcare

 

  

The California Endowment conducted a forum on price transparency in health care. They presented a series of speakers on the ability of health care consumers to determine price information in advance of provider selection for the provision of specific services or groups of services. Work by CalPERs in the past years showed the wide range of costs at different hospitals for common procedures like hip or knee replacements. Those patients may be offered full cost coverage if they utilize a hospital with lower costs or have a larger out of pocket cost if they choose a more expensive provider. In this era of consumer driven healthcare these kinds of initiatives will become more common and we are likely to see additional tools or provider requirements to enable patients to have greater access to price transparency.

 

The impact on radiology of this movement is likely to be great since high end imaging costs can be greater and, as noted in the article above, the patient share of cost will be growing. The Covered California plans have specific patient deductibles for imaging and frequently higher deductibles, $150-250, for CT, MRI and PET imaging. The challenge for radiology is providing relevant information to patients on the reasons for cost variation based upon the facility, type of equipment, physician sub-specialization etc.

 

The Legislature has already established requirements for hospital to make available some pricing information through their charge masters posting. We assume we will see some legislation next year that will make similar proposals for physician fees and charges to provide greater access and transparency to charge/cost information for consumers.

 


Medi-Cal Take Back on Some CT Services

 

  

We heard from several radiology groups that they received a notice in October from Xerox, the Medi-Cal fiscal intermediary, indicating that they would be taking back money on prior payments for CPT codes 74176-74178 paid between 1/1/11 and 6/25/12. They state that the impacted claims were for multiple CTs, same patient same day, and that the PC payment for those claims should have been reduced under the Medicare MPPR.  The CRS contacted Xerox about the notice and indicated that the MPPR for the PC of CT services was not in effect under Medicare at that time and that it therefore is not appropriate for Medi-Cal to try and use that policy to reduce claims reimbursement.

 

As of this writing Xerox has acknowledged the issue but DHCS policy staff are necessary to resolve the issue as to the appropriate time period. We do know that some group who initially had funds withheld have now see that payment action reversed and funds repaid. We will notify members when we have final resolution form DHCS.