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Understanding Health Insurance Plan Coverage [A Video]

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In this YouTube encore video presentation, Ricki Hasou from the MD Anderson Cancer Center talks about knowing your health insurance plan coverage and knowing the terminology behind managed care.

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Assessment

It is very important to understand how your health plan works when you sign up, before you begin making plans for cancer or any other type of medical treatment, and especially if you are leaving your designated healthcare service area.

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An Integrated Approach to Healthcare Network Alignment and Scalable Innovation‏

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[Part 5 in a 6 part series]

By Sam Muppalla – Vice President, McKesson Health Solutions Network Performance Management

Previously, on this ME-P, I wrote about the barriers to alignment across product, network, care and reimbursement innovations. And, yes, I teased you with the three-word preview of what was to come this week: Integrated Building Blocks. The idea of building blocks lies at the heart of an approach to achieving alignment and scaling innovation, so let’s dive in.

Unlocking potential administrative, IT and medical savings — while also creating sustainable alignment of the innovation engines — requires various building blocks be in place as a sound foundation for network design and implementation. These building blocks deliver the required functionality in the most efficient manner. When these building blocks are utilized in an integrated fashion, the current barriers are removed and innovation alignment is achieved.

Four Essential Building Blocks

There are four essential network design automation building blocks that comprise the foundation for innovation: networks, contracting, reimbursement and engagement.

Each of these building blocks enables capabilities by delivering necessary functionality within and across the spectrum of network design. Reaching levels of maturity with this capability unlocks additional value and alignment.

Networks

The network building block enables health plans to differentiate and compete. The purpose is to differentiate their value for each customer segment by aligning the product and care model designs with the underlying network designs. It ensures network performance by facilitating the selection of appropriate providers into networks and the alignment of provider reimbursement with network design objectives. It enables networks to be mapped to member-facing and provider-facing products. The provider-facing products can be used for contracting and provider rate differentiation. The member-facing products can be aligned with benefits and serve as steerage targets for benefit designers.

These constructs, in conjunction with each other, enable productization of care model and payment innovation. For example, a health plan could define a “Medical Home Network” that consists of medical homes and supporting providers in a given geography. It could then enable PCMH-specific reimbursement (e.g., PMPM capitation + Fee For Services (FFS) for preventive services + P4P for EBM) by defining a provider-facing product and associating specific reimbursement policies with that provider product. Additionally, it could also define a member-facing product (e.g., PPO Value) which combines the medical home network with the general market PPO network. This in turn will allow the health plan to define a benefit extension which gives a 10 percent premium reduction to members who use Medical Home Network providers for their primary care. In short, a health plan is now able to monetize its care innovation (PCMH), align benefit design to network design for steerage, and align its provider payment with member incentives (around preventive services), while incenting higher quality care (P4P).

The network building block also achieves administrative cost leadership through comprehensive provider data governance and automation of core provider processes.

Contracting

The contracting building block is designed to enable health plans to reduce contract administrative costs while increasing provider payment accuracy. It optimizes the management of the provider contracting lifecycle through the automation of contract authoring, offering negotiating and acceptance while ensuring the standardization of terms and policies. This building block achieves reduced medical expenditure driven by contract standards adherence, reduced claims mis-payments, and increased speed to market for new payment innovations. It also can support rules-based enforcement of network level reimbursement guidelines to ensure consistent network performance.

Reimbursement

The reimbursement building block enables health plans to maximize the effectiveness of their medical expenditures by paying for value versus volume and by incenting team-based performance. It is the single source of truth for all forms of reimbursement including traditional claims pricing, episodes of care, shared savings, capitation and P4P. This building block enables the mixing and matching of reimbursement methodologies to incent optimal provider performance. It supports a modeling engine to analyze the financial impact of reimbursement and contract changes. It incorporates network-aware provider/contract selection for claims pricing intake. This is a rules driven, high performance service that leverages provider relationship information to select the right provider, the right governing contract and the right reimbursement model for each incoming claim. Additionally, it includes provider transparency services that enable health plan provider portals to support online pricing lookups and reimbursement status/detail inquiries for providers. These services can be extended to support provider performance scorecards and benchmarks.

Engagement

The engagement building block is designed to increase collaboration and participation. It enables meaningful engagement among health plans, providers and members in order to improve health outcomes and reduce costs. This building block achieves reduced administrative and service costs, increased member participation and adherence, increased provider satisfaction and adoption of care/payment initiatives, and the enablement of collaborative/integrated care delivery models such as PCMH and ACO.

Utilizing flexible, automated and integrated building block capabilities is the key to sustainable success that not only unlocks the promise of affordable care to customer segments but also delivers on reduced administrative, medical and IT costs. Incorporating information technologies that can facilitate, if not altogether replace, the manual interactions will be an important part of every organization’s evolution.

Assessment

Next week, in our final part 6 of this series, we’ll wrap up this discussion with a look at some of the potential savings health plans could achieve through alignment and an integrated approach to network design. The potential savings are not slight, so stay tuned. As always, if you just don’t want to wait for next week, visit our website and download the entire Unlocking Affordable Care by Aligning Products white paper; it’s available now.

Conclusion

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Understanding MCO-Medical Practice Contract Standards

The Conversion to Negotiated Managed Healthcare is Significant

Dr. David Edward Marcinko, MBA CMP™

Prof. Hope Rachel Hetico, RN MHA CPHQ CMP™

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The conversion to managed healthcare and capitation financing is a significant marketing force and not merely a temporary business trend. More than 60% of all physicians in the country are now employees of a MCO. Those that embrace these forces will thrive, while those opposed will not.

Developing an Attractive Practice

After you have evaluated the HMOs in your geographic area, you must then make your practice more attractive to them, since there are far too many physicians in most regions today. The following issues are considered by most MCO financial managers and business experts, as they decide whether or not to include you in their network:

General Standards

  • Is there a local or community need for your practice, with a sound patient base that is not too small or large? Remember, practices that already have a significant number of patients have some form of leverage since MCOs know that patients do not like switching their primary care doctors or pediatricians, and women do not want to be forced to change their OB/GYN specialist. If the group leaves the plan, members may complain to their employers and give a negative impression of the plan.
  • A positive return on investment (ROI) from your economically sound practice is important to MCOs because they wish to continue their relationship with you. Often, this means it is difficult for younger practitioners to enter a plan, since plan actuaries realize that there is a high attrition rate among new practitioners. They also realize that more established practices have high overhead costs and may tend to enter into less lucrative contract offerings just to pay the bills.
  • A merger or acquisition is a strategy for the MCO internal business plan that affords a seamless union should a practice decide to sell out or consolidate at a later date. Therefore, a strategy should include things such as: strong managerial and cost accounting principles, a group identity rather than individual mindset, profitability, transferable systems and processes, a corporate form of business, and a vertically integrated organization if the practice is a multi-specialty group.
  • Human resources, capital, and IT service should complement the existing management information system (MIS) framework. This is often difficult for the solo or small group practice and may indicate the need to consolidate with similar groups to achieve needed economies of scale and capital, especially in areas of high MCO penetration.
  • Consolidated financial statements should conform to Generally Accepted Accounting Principles (GAAP), Internal Revenue Code (IRC), Office of the Inspector General (OIG), and other appraisal standards.
  • Strong and respected MD leadership in the medical and business community is an asset. MCOs prefer to deal with physician executives with advanced degrees. You may not need a MBA or CPA, but you should be familiar with basic business, managerial, and financial principles. This includes a conceptual understanding of horizontal and vertical integration, cost principles, cost volume analysis, financial ratio analysis, and cost behavior.
  • The doctors on staff should be willing to treat all conditions and types of patients. The adage “more risk equates to more reward” is still applicable and most groups should take all the full risk contracting they can handle, providing they are not pooled contracts.
  • Are you a team player or solo act? The former personality type might do better in a group or MCO-driven practice, while a fee-for-service market is still possible and may be better suited to the latter personality type.
  • Each member of a physician group, or a solo doctor, should have a valid license, DEA narcotics license, continuing medical education, adequate malpractice insurance, board qualification or certification, hospital privileges, agree with the managed care philosophy, and have partners in a group practice that meet all the same participation criteria. Be available for periodic MCO review by a company representative.

Specific Medical Office Standards

MCOs may require that the following standards are maintained in the medical office setting:

  • It is clean and presentable with a professional appearance.
  • It is readily accessible and has a barrier-free design (see OSHA requirements).
  • There is appropriate medical emergency and resuscitation equipment.
  • The waiting room can accommodate 5 – 7 patients with private changing areas.
  • There is an adequate capacity (e.g., 5,000 – 10,000 member minimum), business plan, and office assistants for the plan.
  • There is an office hour minimum (e.g., 20 hours/week).
  • 24/7 on-call coverage is available, with electronic tracking and eMRs.
  • There are MCO-approved sub-contractors.

Assessment

What have we missed?

Front Matter Link: Front Matter BoMP – 3

 

Conclusion

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Why Health Savings Accounts are No Longer a Banking Industry Pariah

The High Deductible Insurance Competition Heats Up

By Dr. David Edward Marcinko; MBA

[Editor-in-Chief]

As ME-P readers are aware, I’ve had a High Deductible Healthcare Plan [HDHP] coupled with a Health Savings Account [HSA] for my family, and consulting firm, for more than a decade. We’ve been very pleased with it thus far. No significant health problems along the way; just a few scares that proved costly, but benign, because of physician over-protection, over-reaction, or liability phobia; i.e., its better to be safe, than sorry!.

Still, having some economic skin in the insurance game because of the high-deductible feature, makes one an informed consumer. It also provides a sense of empowerment which, while ultimately illusionary for mortals, does offer a bit of self-control. After all, while we can’t mitigate against drunk-drivers and catastrophic diseases, we can live a healthy lifestyle and pay out of pocket for true health “maintenance” … much as we self-pay to maintain our cars and homes, etc. We can do our best … and hope for the rest.

Of course, the savings portion [HSA] has always been a secondary after-thought relative to the actual re-insurance coverage terms, exclusions and conditions. I personally remain focused on the indemnity or PPO type with full coverage, no co-payments and few restrictions. After all, if I use up my high-deductible for an adverse health incident, I figure I have far more problems to worry about than economic. My health, well-being and probably life are significantly in peril.

Nevertheless, as a health economist, I have always appreciated the above market rates given to my cash HSA account; 5% to 4.0% historically; and now 2.5% even after the domestic implosion thru 2010. Compared to the paltry 0.19% in my FDIC protected Wachovia money market deposit account, or the 0.5% in my non-FDIC protected money market mutual fund [brokerage] account; this is a great deal. And, it is tax exempt.

Oh the Irony! 

So, it comes as some surprise that after more than a decade, and the recent health insurance reform political debacle, that there is a surge of interest in the HSA companion. This time however, interest comes not from the insured’s – but the insurers. And, not from the health insurance industry, but rather from the affiliated [and desperate] banking industry.

How so – and why?

Well, it now seems some insurance companies actually desire the business of folks like me who are willing to bear a higher deductible in return for lower premiums, or who are willing to research CPT® code prices and question the efficacy of the procedures they negotiate with physicians in a collaborative fashion; or who are willing to watch their weights and abstain from over-indulgences for their own good. How novel; and again, why?

It’s the HSA pot-o-gold; Duh!

The Proof

Below, is a copy of an email I personally received from eHealthInsurance soliciting my separate health savings account [HSA] business; not my health insurance coverage business:

Dear David,

Did you know that your health insurance plan can be complemented by a Health Savings Account (HSA)? If you haven’t opened an HSA yet, it’s not too late! An HSA allows you to:

  • Use funds to pay for copays, deductibles, prescription drugs, dental services, vision care and more
  • Save money by deducting 100% of your HSA contributions from your taxable income
  • Earn tax-free interest on the funds that accrue in your account over time
  • Grow your account from year to year – the money you contribute won’t expire; you can even use an HSA as a secondary retirement savings account

There are no penalties or taxes when you use your HSA funds to pay for qualified medical expenses. Take advantage of your health plan’s benefits and open an HSA today! eHealthInsurance has partnered with nationally recognized, highly-rated HSA banks to offer you industry leading choices:

  • The Bancorp Bank
  • HSA Bank
  • JPMorgan Chase Bank
  • OptumHealth Bank
  • Sovereign Bank
  • Wells Fargo Bank

We’re with you every step of the way

Our representatives are also available for online chat 24 hours day.

Gary Matalucci
Vice President of Customer Care

The Question Is?

Such the deal; NOT!

So, any thinking HDHP participant [like me] must logically ask why such “nationally recognized, highly-rated HSA banks” would offer above market rates during these times of essentially zero interest rate levels.  Why the interest at all? Are they trying to loose money; or are they just befriending me?

As tennis player John McEnroe might say: are you serious!

Assessment

Yes John, the high rates are a serious loss-leader for more expensive products.

These banks want to make money; not from the non-existent interest rate spread on your HSA cash, but by enticing us to place this growing cash horde into their “investment vehicles.”  In the recent past, some of us mortgaged our homes chasing the stock market or were goaded into flipping houses. And now, these same bankers are encouraging us to mortgage our health insurance on whatever high-priced, low-quality, fee-ridden, load bearing, snarky “investment vehicles” they can pawn off on us.

Of course, the health insurance companies get a fat sales commission or percentage cut, as well. A win-win situation for all but us – the insured.

Think AARP.

My Personal Advice

Do not do it. Do not take the bait.

The HSA portion of your HDHP is for paying premiums and future medical care in the event of a health catastrophe. It is for savings, not for investing in a risk-bearing vehicle. Far too many of us realized too late that a home is a place to live – not an investment. Likewise, a health savings account is for your health, and health insurance – not risky investing.

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Assessment

Well, that’s my opinion as a retired surgeon, former insurance agent and financial advisor.

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Janis Oshensky Lobbies Congress – Not Dentists

Show Me the Math

By Darrell K. Pruitt; DDSpruitt 

I have noted here far too many times how it disappoints me that Delta Dental Plans Association vice president Janis Oshensky repeatedly chooses to turn to politicians rather than discuss Delta Dental’s arguably egregious and harmful policies with me, a dentist. I intend to put a stop to such disrespect one PR expert at a time if necessary.

Long ago I warned Oshensky that if she didn’t talk to me, she should probably just shut up in order to preserve what’s left of her Internet reputation. Since by posting her Letter to the Editor on POLITICO.com today, she obviously ignored my advice, this highly critical comment will reliably join three others of mine on her first page soon enough. Her employer is sacrificing her like a pawn.

The following comment is the one I posted on POLITICO.com in response to Oshensky’s letter. It might just help the vice president to finally come to a decision on this issue one way or the other. Either way, marketplace conversation like this cannot help but lead to safer air for the community … My pleasure.

http://www.politico.com/news/stories/0709/24873.html

Dear POLITICO.com Editor:

This comment and subsequent invitation to Janis Oshensky is in response to the Delta Dental Plans Association vice president’s July 14, 2009 letter to you. Her letter is the most recent message she successfully sent Congress using a political news Website. Even though Ms. Oshensky holds the position of VP of dental relations as well as public policy, she has avoided answering this dentist’s questions about Delta Dental’s policies for months. If Ms. Oshensky is willing to do so, I would love for her to join me in discussion of Delta Dental’s taxation subsidy right here on POLITICO.com so that our lawmakers can witness a more balanced view of the issues.

Hello – It’s Me

Hello. My name is D. Kellus; Pruitt DDS, and I’m a practicing dentist in Fort Worth, Texas. It is my professional opinion that my patients are harmed by the policies of managed care dental plans like that sold by DDPA because there is no accountability to their clients or dentists. There is barely any accountability to those who select and pay for Delta’s products – dental patients’ naive bosses.

Like virtually every US citizen, your readers probably couldn’t care less about the dental industry. It is precisely because dentistry has been uninteresting for decades that make the microcosm of health care incredibly interesting to me. Let me uncover for your appreciation the event horizon in dental history. You could learn about more than just dentistry.

If left to natural forces of human nature, what happens to value when there is no accountability? For example, what do the 1975 East German Trabant and the 1979 Ford Pinto have in common? By popular vote, those products not only represent the two worst automobiles ever made, but the state shielded both manufacturers from accountability to consumers. Poor quality happens.

Oshensky argues against the taxation of managed care dental benefits like those sold to employers by Delta Dental. Let me offer that if Delta’s product were taxed like income, its value would quickly dive below the market threshold that attracts purchasers’ consideration.

Allow Me to Show-You the Math

Recently, Delta Dental of Michigan lost the accounts of thousands of GM retirees when their group dental benefits were cut in bankruptcy negotiations with UAW. Suddenly, Delta found itself forced to market their product to individuals who for once have the choice to keep their money. Faced with true competition for healthcare dollars, Delta leaders desperately cobbled together individual policies for the retirees who want to continue with their coverage. Even though Delta did everything possible to lower the cost of their coverage, the cheapest of the plans they offered still runs about $30 per person per month, and covers only 50% of everything, including preventive. So for premiums of $360 per year plus half the preferred providers’ 20% to 30% discounted fees, is this a bargain for Michigan retirees?

Free Markets 

In my free-market, fee-for-service practice, if a patient comes in for two cleanings and routine x-rays during a year, 100% of my bill is $208. This is the market price in my neighborhood that is continually challenged by lively competition with other dentists for new patients who may not even have dental benefits. Those customers pay in full at the time of visit, just like most people whose bosses purchased Delta Dental Plans.

Value Comparisons

So let’s compare value of Delta Dental’s product with cash. If I were a Delta Dental preferred provider, my fee of $208, less Delta’s 25% discount would be $156. Never mind that my wife has problems with my 70% cut in pay, let’s move on. 

The patient’s half of the $156 I earned is $78. $360 + $78 = $438. So for one uneventful year of discounted dental services with a dentist chosen from a list of names, a patient can expect to spend more than twice as much than if they paid the free-market price at the point of service.

Assessment

Not only is that hardly a bargain, but it is my opinion that managed care dentistry is dentistry by the lowest bidder with no quality control. That should be enough meat to get this conversation rolling. Now it’s your turn Ms. Oshensky. I think you have to admit that you’ve got holes to mend in the dental relations part of your job.

Conclusion

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On Growing Tensions in Healthcare Services Markets

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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

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Advisor’s Checklist for Physicians Seeking Insurance

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

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Paradigm Shift to “Defined Health Contributions” from “Defined Health Benefits” Plans

What it is – How it Works

By Staff Reporters

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In the past, according to Robert James Cimasi MHA AVA CMP™ of Health Capital Consultants LLC in St. Louis MO, many employers had defined retirement benefits for employees. Today, most retirement benefits are in the form of 401K plans where companies make defined contributions, effectively shifting the financial risk of paying for retirement to employees.

Defined Health Contributions

Defined health contributions are similar to employer-funded defined retirement contributions like 401K plans. Currently, employers pay for some portion of about half of Americans’ health insurance. Traditional employer-funded plans are those for which the employee simply fills out a form; that is, an employer will offer one or possibly two health insurance plans, and the employee fills out application paperwork. The employer administers the plan and may charge the employee a portion of the monthly premium or pay the entire premium themselves. A defined contribution plan allows companies to shift the financial risk of paying for rising health insurance costs.

Defined Health Benefits

Although part of the “benefit” of a health benefit plan is that the employer also takes care of all the administrative paperwork related to the insurance, companies are increasingly uninvolved in the administration process, opting instead to let the employee decide which plan out of many choices suits them best. For example, if an employer typically spends about $5,000 per employee per year on health benefits, the employer would use that money as a “defined contribution.” The employee then has $5,000 to spend per year on benefits, but instead of using the employer-defined health plan, the employee may choose from a variety of HMOs, preferred provider organizations PPOs, or other health plans. If the insurance premiums rise above this amount, the employee must make up the difference.

dhimc-book24Defined Contribution Package

Many employers are currently offering a defined contribution package to their employees. The definition of “defined contributions,” however, can range from one in which employers are completely uninvolved in the administration of benefits and simply give their employees cash or vouchers for the amount contributed that they can use to buy coverage, to a more “defined choice model” where employers offer a variety of health options at differing price levels along with a premium dollar contribution, and a variety of other options in between.

Risk Shifting

Thus, defined contributions shift the financial risk from the employer to the employee. Defined care is not a replacement for managed care, but will probably cause managed care to adapt under these new systems. That is, HMOs, PPOs and other managed care plans still appear to be the main choices in a defined care environment, so they are in fact a part of the system.

Assessment

Another challenge with a defined health benefit program is that the concept of risk-pooling becomes more difficult. In traditional employer-sponsored plans, rates are usually based on the pool of employees; a chronically ill employee who tries to find insurance independently may face rates drastically higher than if they had participated in an employer-sponsored plan.

MORE: www.CertifiedMedicalPlanner.org

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Understanding Modern Health Plan Delivery Models

By Defining Terms and Concepts

Staff Writers

www.HealthcareFinancials.comho-journal10

Here are four important health care delivery models that should be understood by all financial advisors, their clients, patients and the public:

1. PHYSICIAN ORGANIZATION (PO)

A PO is a group of physicians banding together, usually for the purpose of contracting with managed care entities, or to represent the physician component in a Physician Hospital Organization. The PO is a managed care contracting entity owned by and composed exclusively of physicians. The PO tends to be more tightly controlled in terms of members and adherence to treatment protocols than an Independent Physician Association. POs typically share information systems, claims-processing procedures, financial data, medical records, and other technical support functions.

2. PHYSICIAN PRACTICE MANAGEMENT CORPORATION (PPMC)

A firm that purchases physicians’ practices in exchange for a percentage of the gross receivables. The PPMC leases the office back to the doctor or employs the doctor on a salaried basis. The PPMC then contracts with the areas MCOs.

3. POINT OF SERVICE PLAN (POSP)

A type of managed care plan that allows members to choose whether to seek medical care within the plan’s network or seek medical care out of network at the point of service (i.e., at the time services are rendered). It allows members to pay little or nothing, if they stay within the established HMO delivery system. But, it also permits members to choose and receive services from an outside doctor, any time, if they are willing to pay higher co-payments, deductibles and possibly monthly premiums. It is also called an “open-ended” plan.

4. PREFERRED PROVIDER ORGANIZATION (PPO)

A PPO is a select, approved panel of physicians, hospitals, and other providers who agree to accept a discounted fee schedule for patients and to follow utilization review and pre-authorization protocols for certain treatments. It is a system in which a payer negotiates lower prices with certain doctors and hospitals. Patients who go to a preferred provider get a higher benefit — for example, 90% or 100% coverage of their costs — than patients who go outside the network.

Assessmentdhimc-book20

Link: www.HealthDictionarySeries.com

Conclusion

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Link: https://healthcarefinancials.wordpress.com/2009/03/13/rip-retail-financial-services-industry/

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Understanding MD/DO HMO Contracts

Pitfalls Physicians Must Avoid

By Dr. David Edward Marcinko; MBA, CPHQ, CMP™

By Hope Rachel Hetico; RN, MHA, CPHQ, CMP™

[Publisher-in-Chief and Managing Editor]dave-and-hope5

It is well known that stakeholders of the healthcare industrial complex often have different, and divergent, interests. Intra-as well as inter-stakeholder competition occurs; as well.

The Friends-Enemies [“Frenemies”]

For example, several decades ago, the authors were often at odds at the payer negotiation table.

He was managing partner of a large private medical practice, ASC and later PPMC. First, she was the representative of a national DME vendor, healthcare system and later, private insurance payer.

Key Pit Falls to Avoid

There are seven key pitfalls to watch out for when evaluating an MCO contract.

1.  Profitability: Less than 52% of all senior physician executives know whether their managed care contracts are profitable. “Many simply sign up and hope for the best”.

2. Financial Data:  90% of all executives said the ability to obtain financial information was valuable, “yet only 50% could obtain the needed data”.

3.  Information Technology: IT hardware and sophisticated software is needed to gather, evaluate and interpret clinical and financial data; yet it is typically “unavailable to the solo or small group practice”.

4. Underpayments: This rate is typically between 3-10% and is usually “left on the table”.

5. Cash Flow Forecasting: MCO contracting will soon begin yearly (or longer) compensation disbursements, “causing significant cash flow problems to many physicians and physicians”.

6. Stop Loss Minimums: SLMs are one-time upfront premium charges for stop loss insurance. However, if the contract is prematurely terminated; you may not receive a pro-rata refund unless you ask for it!

7. Automatic Contract Renewals: ACRs or “evergreen” contracts automatically renew unless one party objects. This is convenient for both the payer and payee, but may result in overlapping renewal and re-negotiation deadlines. Hence, a contract may be continued on a sub-optimal basis, to the detriment of the provider. 

biz-book5

Assessment

Always remember, in the game of negotiations, today’s enemy – may be tomorrow’s ally.

Conclusion

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Direct Reimbursement [DR] and RiskManagers.Us

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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

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The No Insurance Club

Emerging Pre-Paid Cash-Based Medicine

By Bob Grove

no-insurance-clubHealthcare in America is in Turmoil. The No Insurance Club [NIC] feels private contracts may be the solution. More and more Americans are going without healthcare especially preventative healthcare. The reasons – costs are too high, patients can’t get accepted due to a pre-existing condition, companies are cutting back on benefits, people have been laid off from work; and the list goes on.

Governmental Solutions 

What’s being done to improve healthcare? Barack Obama and the Government want more control and regulation and the system seems to be leaning toward socialized care. Private insurance companies continue to increase premiums, which prices healthcare out of reach for the average American. Employers can no longer float the cost of insurance so they pass it on to their employees. Patients aren’t the only ones being affected by the current state of healthcare. More and more doctors are going out of business and hospitals are cutting back due to escalating costs and payment defaults.

Private Solutions 

The current remedy; Americans are taking out private major medical policies for catastrophic events with high-deductibles [MSA/HSAs] to keep monthly premiums down, or are turning to Medicaid, mini retail-clinics at grocery stores/pharmacies, and emergency room visits for common illnesses.

Innovative Solutions 

What about prevention and maintenance? More than 90 percent of health related issues can be taken care of with preventative care and maintenance but only a small percentage of Americans currently enjoy the benefit of preventative healthcare.

The No Insurance Club

The NIC has come up with a fresh look at healthcare by offering an affordable alternative to traditional insurance options.

NIC Benefits and Features 

The No Insurance Club connects patients with participating board certified physicians that will treat and care for preventative healthcare needs for a one-time prepaid annual membership fee:

   

  • NIC patients make a one-time annual payment that is typically less than a one-month premium with traditional insurance.
  • Patients receive up to 12 office visits per year that also include immunizations, $4 or less in-office prescriptions, and additional services including blood tests.
  • No deductible, no co-pays, no premiums.
  • No surprise bills to patients.
  • Viable alternative to COBRA for employees laid off from work.
  • Low cost option for the self-employed.

Assessment

What’s in it for the doctors? How about no insurance clerks, no need to snail mail medical insurance claims or use expensive electronic claims submission clearinghouse services, no bad debts or bad expense write-offs, no ARs; and fast cash! 

Link: http://www.noinsuranceclub.com/

I would be happy to speak with and connect ME-P readers, participating doctors and even patients for interviews to learn more about the NIC network and its benefits.

Bob Grove

Wild West PR

(801) 651-0290

bob@wildwestpr.com

Conclusion

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