Take Your Corners – Hospital Health Plan Negotiation Strategies

Hospital managed care teams need to understand their markets are much more expansive than other hospital competition, advises, a senior exec with a company that provides a range of services to providers.

“Essentially, there are three basic ways of dealing with negotiation differences: Continue reading

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Bundled Payments May Be Another Developing Trend to Watch: Anthem Adopts Bundled Payment Agreements For Two Providers

Anthem BCBS has entered into “bundled payment” arrangements for select surgical procedures at the Orthopedic & Sports Institute of the Fox Valley in Appleton, Wis. and at Manitowoc Surgery Center in Manitowoc, Wis.

A “bundled payment” groups and coordinates all of the charges associated with a surgery and recovery together for one pre-negotiated price. This means an individual can quickly and easily understand their potential out-of-pocket costs before surgery and results in greatly reduced paperwork for all involved.

“Think of a bundled payment like a restaurant offering a complete meal for $20 deal,” said John Foley, regional Continue reading

25 Percent of Provider Reimbursement Seen Tied to Performance

Over the coming decade, a third (35 percent) of doctors expect that between 10 percent and 25 percent of provider reimbursement will be tied to performance.

And, a fifth (22 percent) of doctors think that the proportion at risk will be in excess of a quarter of reimbursement.

Half (49 percent) of physicians say they currently feel “not at all prepared” to accept greater financial risk for managing patient care, found a study by the Optum Institute for Sustainable Health.

http://www.institute.optum.com/

Evaluating Oncology Management Programs: Trends in Payer Oncology Management and What You Need to Know for Success

MANASQUAN, NJ — Payers and providers across the country are grappling with choices for programs regarding oncology management and potential collaboration to control costs while also increasing the effectiveness of care.

There is a lot of discussion and many models being proposed for management of oncology costs. Both physicians and payers are seeking information to help in separating the wheat from the chaff and looking for help in choosing the best model for their needs especially in this challenging climate.

Evaluating Oncology Management Programs:Trends in Payer Oncology Management and What You Need to Know for Success is a 60-minute audio webcast scheduled for December 2, 2010, at 1:30 p.m. EST.

This program identifies the issues of concern in oncology management, outlines the current seven models under discussion/implementation, and reviews the players, pros and issues with each model.

Participants will learn how to:

  • Evaluate the results of two oncology trend reports while learning key perspectives on oncology policy and management from both payers and physicians as well as implications of the study results
  • Review the details of oncology management and collaborative models in play across the country, including drug pricing, guidelines and pathways
  • Understand how to evaluate the current models and what questions to ask in choosing a best fit for your organization
  • Develop strategies regarding oncology management and take away steps for implementation and collaboration with oncology providers

The session also includes:

  • Live Open Line question and answer session

The presenter for the program is Dawn G. Holcombe, president of
DGH Consulting and is sponsored by The Managed Care Information Center.

For complete details, please visit:
www.healthresourcesonline.com/edu/Evaluating-Oncology-Management-Programs.htm

Denying Coverage To Those With Pre-Existing Conditions Subject Of New Federal Report

Just in time to add fuel to the health insurance reform debate, the federal Department of Health and Human Services (HHS) has shone a spotlight on the industry’s practices of denying coverage to individuals with pre-existing conditions.

The report, “Coverage Denied: How the Current Health Insurance System Leaves Millions Behind,”scrutinizes health insurance company practices of denying coverage to or discriminating against Americans who have pre-existing medical conditions.

HHS noted that a recent national survey found that 12.6 million non-elderly adults – 36 percent of those who tried to buy insurance on the private market – were discriminated against in the past three years because an insurance company deemed them ineligible for coverage because of a pre-existing condition, charged them a higher premium, or refused to cover their condition.

“Another survey found 1 in 10 people with cancer said they could not get health coverage, and 6 percent said they lost their coverage because of their diagnosis,” HHS said.

The insurance company practice of denying coverage because of pre-existing conditions is not confined to serious diseases, the report noted. “Even minor problems such as hay fever could trigger prohibitive responses.”

“In 45 states insurance companies can discriminate against people based on their pre-existing conditions when they try to purchase health insurance directly from insurance companies in the individual insurance market. Insurers can deny them coverage, charge higher premiums, and/or refuse to cover that particular medical condition,” said the report.

An insurer could charge high premiums, deny coverage, or set a restriction such as denying any respiratory disease coverage to a person with hay fever, according to the report.

Some insurance companies respond to an expensive condition such as cancer by initiating a thorough review of the patient’s health insurance application. If the company discovers that any medical condition, regardless of how minor, was not reported on the application, it could revoke coverage retroactively for the patient and possibly all members of the patient’s family, the report said. The practice is known as rescission.

Companies can do this even if the condition found is not related to the expensive condition or if the person wasn’t aware of the condition at the time, the report charged.

“At least one company encouraged employees to revoke sick people’s health coverage through rescissions,” the report said.

“When a person is diagnosed with an expensive condition such as cancer, some insurance companies review his/her initial health status questionnaire. In most states’ individual insurance market, insurance companies can retroactively cancel the entire policy if any condition was missed – even if the medical condition is unrelated, and even if the person was not aware of the condition at the time,” the report said. “Coverage can also be revoked for all members of a family, even if only one family member failed to disclose a medical condition.”

Under terms of the proposed health insurance reform currently being debated in Washington, insurance companies would be prohibited from refusing coverage based on someone’s medical history or health risk. “Companies also would be barred from watering down coverage or refusing renewal because someone becomes sick,” the report noted. Companies would have to renew any policy as long as the policyholder pays the premium in full.

The report is available at www.HealthReform.gov.