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Practices Should Prepare for Payer Consolidation

Practices Should Prepare for Payer Consolidation | Healthcare and Technology news | Scoop.it

We live in a very exciting time in the healthcare industry. Regardless of how you feel or think about decisions that are made on the government level, healthcare is in a period of controlled chaos right now.


With the potential merger of Anthem and Cigna and Aetna and Humana, or Assurant closing its doors on its health insurance business, things are about to get really interesting for medical practices. Arming yourself with as much information as possible is key to not just surviving financially, but thriving in this new environment.

Let's take Assurant, for example. They've decided that doing business in the healthcare arena and competing against the dominant healthcare insurance companies was far more expensive than expected. What does this mean for your practice? If you have patients that use Assurant as their medical insurance, it's a great idea to step in and take control of those accounts, now. Create a waiver for Assurant patients that explains what is going on, what to expect from their plan, and how they can still see you with a new insurance plan. The waiver should also state that in the event Assurant does not pay the medical claim, patients will be responsible for the allowed amount, and they will have to pay out of pocket if it is a PPO Plan. If the plan is an HMO, and Assurant does not pay, the practice is not allowed to place a PR (patient responsibility) to the patient and will lose that money.


Aetna and Assurant have similar fee schedules, so suggest to your patients to look into individual Aetna plans, to ensure that you will retain those patients and not lose revenue if you are contracted with Aetna. You will also need to really follow up with those claims and make sure that Assurant is paying you. I have seen them use a delaying tactic of denying a claim with the code CO95 (plan procedures not followed), which basically means they are sending your claim to a different claim address than what was provided to you at the time of benefit verification.  


As far as the pending mergers, I really love it when this happens. I'm particularly fond of the companies that have been courting each other lately. With the possible Aetna/Humana merger, Aetna will be able to add a lot more patients to their network. It will position them as a real player and earn them much needed respect within the market. I still have some overall issues with both Aetna and Humana, but merging them together should ease some of those issues.


The Anthem/Cigna cat-and-mouse game going on is particularly interesting. Cigna claims they're worth more than $184/share, and said no to Anthem's last purchase attempt. But Anthem is not giving up. Cigna used to be a premium plan until they teamed up with American Specialty Health. They have basically cut reimbursements to providers in half (if you signed up under their new network, otherwise you are seeing Cigna patients out of network), and implemented a time-consuming authorization process that eats away at whatever profit your practice may have left over from the reimbursement cuts. They implemented this over the course of the last year, or so. Working with Anthem is pretty cut and dried: What you see is what you get, with no hidden agendas. Anthem requires few to no pre-authorizations, allowing you to see your patient and maybe make a few bucks.


Just taking a few moments and reading up on what is going on in the healthcare industry today is really key to insuring your practice is not caught off guard. Always be learning, always be aware. There are multiple newsletters you can sign up for that will drop a daily or weekly e-mail into your inbox that will help you keep up.

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Hospitals fight to charge you more

The Centers for Medicare and Medicaid Services (CMS) has put its foot down, this time on the side of patients. Many hospitals charge you more for the same outpatient tests you get in your doctor’s office. Sixty-six different services are being targeted by CMS to leverage the playing field.

Are the tests really all that different?

We are not talking about inpatient tests that happen when you are sick enough to be admitted to the hospital. We are talking about tests that are offered by different departments in a hospital. For example, you could have an echocardiogram performed at your cardiologist’s office, or you could have one done at the hospital. The acuity of your medical condition is the same. The equipment used is the same. The same doctor may even interpret the test. The only difference is geography.

If CMS paid the same dollar amount for a test wherever it was performed, it is estimated they could save $1.44 billion every year. Others  estimate savings of $29.5 billion over ten years. That may sound great to you and me, but the idea of “site-neutral” payments has hospitals fighting to charge you more.

The American Hospital Association would like to tell you that they need to charge higher costs for a number of reasons. They need that added income to help pay for staffing and to prepare for disaster readiness and other operational expenses at their facilities. As resources for their communities, they provide access day in and day out for emergencies and care for vulnerable populations — the poor, the underinsured, and the underserved — that may not have access to care by doctors in an outpatient setting.  After all, not all doctor’s offices accept Medicare these days. Add to that the fact that hospitals report financial losses from Medicare for a variety of reimbursement issues.

What about the patient in all of this? Hospitals no doubt are a valuable resource, but these arguments by the AHA do not address the issue of expense to the patient and why directly increasing costs for these particular tests is justified. There must be other ways to generate revenue than on the backs of their patients.

Medicare is not free and pays for only 80 percent of the large majority of outpatient tests. Charging more unfairly increases the financial burden for American seniors. Aren’t they a vulnerable population too?

The decision about site-neutral payments is not yet final, but the debate is underway. In the meantime, if you are a health care provider who offers outpatient testing in your office, consider that your first option before sending your patients to the hospital. Remember who you are supposed to be caring for: the patient.


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