On Growing Tensions in Healthcare Services Markets

Posted on June 21, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Join Our Mailing List

Stressors Affecting all Stakeholders

[By Robert James Cimsai; MHA, AVA, ASA, CMP™]

http://www.HealthCapital.com

The changes in reimbursement for Medicare services through the introduction of prospective payment systems and physician reimbursement cuts for professional services, as well as the increased focus on patient quality and transparency initiatives and health 2.0 collaboration have forced healthcare providers to look for more efficient ways to provide services, as well as additional sources of revenue and margin-producing business.

Additionally, with the rise of corporate healthcare provider networks and health systems, together with rising healthcare costs, competition among providers has become prevalent in the healthcare industry.

Assessment

Strict control of reimbursement costs from payers and consistent decreases in physician professional component fee reimbursement yields; reduction in traditional hospital inpatient use; and higher costs of capital have all contributed to the trend of physician investment in outpatient (and inpatient) specialty provider enterprises [ASCs, specialty hospitals and clinics, etc] , which often compete with general acute care community hospital providers.

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Product Details 

Filed under: Career Development, Health Economics, Health Insurance, Health Law & Policy, Healthcare Finance, Practice Management | Tagged: , , , , , , , , , , , , , , | 6 Comments »

Advisor’s Checklist for Physicians Seeking Insurance

Posted on May 3, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Background, Education, and Certifications

By Dr. David Edward Marcinko; MBA, CMP™

Publisher-in-Chiefdem22

The following are sample questions and information gathered for Professional Liability Coverage

The Checklist

**Medical specialty information by percentage of practice.

**Information on medical education, including information on medical school, internship information, residency information, and fellowship information, if any.

**Information on medical experience, including information on military discharge (DD214), public health service, moonlighting, ‘locum tenens’, and private practice information. Have dates and locations available. Other information includes:

  • Information on completed continuing education hours in the past two years.
  • Publications, speeches, instruction, etc.
  • Information on medical licenses, including state, license number, expiration dates, and current status.
  • Information on board certifications.
  • The above information may be contained in a Curriculum Vita, if you have one.
  • On an “as applicable” basis:
  • Complete details including dates and outcomes of any board certification revocations or suspensions, license revocations or suspensions, alcohol or drug addictions and treatments, criminal or sexual misconduct charges, or Medicare or Medicaid charges.
  • Previous Insurance Information
  • Insurance history, including the name, policy number, whether the coverage form was occurrence or claims made, policy period, limits of liability, deductible amount, and prior acts date, for your current carrier, and your first, second, third, and fourth prior carrier, if applicable.
  • Information on any insurance company cancellations or non-renewals.
  • If your current policy is a claims-made policy, whether you are obtaining tail coverage from your current insurance company.
  • Copies of prior policies, if available.

Current Medical Practice Information

  • Information on supervision and employment of residents, physician assistants, nurse practitioners, CRNAs, nurse midwives and other physicians;
  • Information on networks or managed care organizations associated with (IPA, PHO, MSO, etc.), including group name, type of organization, and relationship;
  • Information on other contractual relationships other than PPOs, HMOs, IPA, etc;
  • Full information on all hospital privileges, including hospital name, location, and type of privilege.
  • Information on any suspension, denial, revocation, restriction, or other sanctioning of hospital privileges.

Classification and Specialty Identification

Full information on procedures performed, including details of surgeries, average number of patients seen weekly, specialty practice areas, etc.

Prior Claims History (if any)

For each claim, patient’s name; date of occurrence; insurance carrier; location of occurrence; date claim was reported; date claim was closed (if applicable); copies of subpoenas, pleadings, or judgments; amount reserved on your behalf; and amount paid on your behalf.  Provide as complete a description of the allegations as possible.

insurance-book2

Important Note

This checklist is provided as a guide to assist the Healthcare Professional in gathering the information that insurance companies typically request.  Discuss this checklist with your agent to identify additional information as needed.

Assessment

The author has been an expert medical witness in both state and federal court. He is also a former licensed insurance agent and certified financial planner.

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest E-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Filed under: "Advisors Only", "Doctors Only", Career Development, Health Law & Policy, iMBA, Inc., Insurance Matters, Practice Management, Professional Liability, Recommended Books, Sponsors | Tagged: , , , , , , , , , , , , | Leave a comment »

Understanding the Health Maintenance Organization Delivery Model

Posted on April 24, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

ho-journal8Defining Terms and Concepts

By Staff Writers

www.HealthcareFinancials.com

An HMO is a legal corporation that offers health insurance and medical care. It is a health care delivery system that provides comprehensive services for subscribing members in a particular geographic area. Most HMO care is provided through a managed network made up of MD/DOs, hospitals, and other allopathic/osteopathic professionals selected by the HMO. HMO enrollees are required to obtain care from this network of providers in order for their care to be covered, except in cases of emergency. All the care the members may need is paid for by the single monthly fee, plus nominal co-payments. HMOs typically offer a range of health care services at a fixed price (capitation).

Different Types

The types of HMOs are:

1. STAFF MODEL: Organization owns its clinics and employs its doctors.

2. GROUP MODEL: Contract with medical groups for services.

3. INDEPENDENT PHYSICIAN ASSOCIATION (IPA) MODEL: IPA contract that in turn contracts with individual physicians.

4. DIRECT CONTRACT or NETWORK MODEL: Contracts directly with individual physicians.

5. MIXED MODEL: Members get options ranging from staff to IPA models.

6. OPEN-PANEL MODEL: A managed care plan or HMO where members can see any provider for an extra premium cost.

Assessmentdhimc-book18

Link: www.HealthDictionarySeries.com

Conclusion

And so, your thoughts and comments on this Medical Executive-Post are appreciated?

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com  or Bio: www.stpub.com/pubs/authors/MARCINKO.htm

Get our Widget: Get this widget!

Our Other Print Books and Related Information Sources:

Practice Management: http://www.springerpub.com/prod.aspx?prod_id=23759

Physician Financial Planning: http://www.jbpub.com/catalog/0763745790

Medical Risk Management: http://www.jbpub.com/catalog/9780763733421

Healthcare Organizations: www.HealthcareFinancials.com

Health Administration Terms: www.HealthDictionarySeries.com

Physician Advisors: www.CertifiedMedicalPlanner.com

Subscribe Now: Did you like this Medical Executive-Post, or find it helpful, interesting and informative? Want to get the latest ME-Ps delivered to your email box each morning? Just subscribe using the link below. You can unsubscribe at any time. Security is assured.

Link: http://feeds.feedburner.com/HealthcareFinancialsthePostForcxos

Filed under: "Ask-an-Advisor", Book Reviews, Career Development, Glossary Terms, Health Insurance, iMBA, Inc., Managed Care | Tagged: , , , , , , , , , , , , , , , , | 1 Comment »

Direct Reimbursement [DR] and RiskManagers.Us

Posted on April 6, 2009 by Dr. David Edward Marcinko MBA MEd CMP™

Join Our Mailing List

Transparent Dental Benefits versus Confusion

[By Darrell K. Pruitt; DDS]

pruitt

“If you are not a part of the solution, there is good money to be made prolonging the problem.” 

Company slogan- www.riskmanagers.us

Meet Mr. William Rusteberg

Today, I met William Rusteberg on the PennWell forum when he replied to the thread, “Why the long NPI, BCBS-TX?” which I copied below, along with my response which includes a plug for Direct Reimbursement [DR].

http://community.pennwelldentalgroup.com/forum/topics/why-the-long-npi-bcbstx?page=1&commentId=2013420%3AComment%3A26976&x=1#2013420Comment26976

Mr. Rusteberg represents a company called RiskManagers.Us, whose specialty involves the benefits market, yet it is not exactly an insurance company – just like there is no such thing as true dental insurance.  RiskManagers.us is a firm that works directly with businesses to identify and develop cost-effective benefits packages – emphasizing transparency and fairness.  Now that is refreshing, friends! 

Defining RiskManagers.Us 

Here is how RiskManagers.us describes itself: 

“We do not work for an insurance company, we work for you. As an independent brokerage, and consulting firm we can represent any licensed insurance company in Texas, Colorado, Mississippi, Louisiana, Alabama, Illinois & Florida.”

If one visits the Web site’s “Reference Library,” here are some of the topics offered:

·         Self Funding – Need a second opinion?

·         Texas leads in transparency issues

·         Can’t get claim information? HB 2015 May Solve Your Problem

·         Medical Stop Loss Through a Captive

·         PPO Discounts – Games People Play

·         PPO Networks – Shell Game

·         Can Hospitals waive Deductibles in Texas?

“What is a NPI number?” 

Mr. Rusteberg’s initial question on the PennWell forum simply asked, “What is a NPI number?”  Following my explanation, he wrote: 

 “It seems that many of those in your profession would do well in accepting cash only, or directly working with employer groups who sponsor dental/medical plans on a direct pay basis. We have had good success in doing this for our clients – we have one employer in San Antonio who pays medical care providers directly and quickly – providers like it and the plan pays a fair and reasonable rate, not relying on a PPO network to “re-price” claims. We have done the same on dental plans, eliminating the insurance company, PPO network and paying dental care providers submitted charges directly and quickly. We see little or no trend increases on dental charges using this method. In my view, insurance companies interfere in patient – provider relationships in a financially detrimental way.”

Thanks for your reply.

My Response:

I like you, William; 

What you describe sounds like my all-time, personal favorite dental benefits plan. It is called Direct Reimbursement {DR}, and it not only gives the employer the unlimited capability to design a plan which reflects the level of commitment desired by the company, but most importantly, it naturally preserves quality of care by allowing employees unlimited freedom of choice in dentists.  And that’s as good as the market gets. 

http://www.directreimbursement.com/

In addition, since there are no NPI requirements for DR, employees are also permitted see dentists who decline NPI numbers for ethical reasons. That increases employees’ choice by 50% over BCBS-TX clients, according to recent information provided by the Healthcare IT Transition Group.

http://www.npidentify.com/stats.htm#states

Little Management Needed

Just like the benefits plans you mention, with DR, very little money is spent on management because such policies are so simple and transparent that there is no room for profit-enhancing (wasteful) confusion used by unethical companies like BCBSTX, Aetna, Cigna, UnitedHealth, Delta Dental, United Concordia, and so many other members of the National Association of Dental Plans (NADP).

Assessment

Without transparency and the invisible hand of freedom-of-choice, free-market competition for healthcare dollars disappears as fast as executive bonuses rise. We’ll see where it goes from here. It would sure be swell if a Direct Reimbursement representative takes interest in the conversation; anyone home? 

Conclusion

Your thoughts and comments on this ME-P are appreciated. Feel free to review our top-left column, and top-right sidebar materials, links, URLs and related websites, too. Then, subscribe to the ME-P. It is fast, free and secure.

Speaker: If you need a moderator or speaker for an upcoming event, Dr. David E. Marcinko; MBA – Publisher-in-Chief of the Medical Executive-Post – is available for seminar or speaking engagements. Contact: MarcinkoAdvisors@msn.com

OUR OTHER PRINT BOOKS AND RELATED INFORMATION SOURCES:

Product DetailsProduct Details

Filed under: "Doctors Only", Breaking News, Career Development, Ethics, Health Economics, Health Insurance, Managed Care, Op-Editorials, Practice Management | Tagged: , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , | 12 Comments »