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Category Archives: Managed Care Contracting
Exchange Plans Could Undermine ER Safety Net
Most everyone assumes that the Patient Protection and Affordable Care Act (PPACA) facilitated Exchange Plans, by increasing the number of insured patients and reducing the rolls of the uninsured, will generate additional revenues for hospital Emergency Departments and emergency physicians. However, the net effect of these Exchanges and other aspects of the ACA could spell disaster for many emergency care safety net providers. On the surface, it appears the PPACA should have a positive impact … Continue reading
Compensating Emergency Physicians: If Not Fee-for-Service, What?
The push for payment reform in US health care is getting a great deal of support from every corner, and this will impact compensation for emergency physicians just as it will for nearly every specialty. Nearly everyone believes that our fee-for-service reimbursement system results in too much care for too little benefit. The perception that preventative and primary health care services are undercompensated, and procedural services to rescue failing health are overcompensated, seems to be … Continue reading
The Erosion of Out-of-Network Leverage in Health Plan Contract Negotiations
One of the hard lessons I have learned in negotiating health plan contracts for physician groups is that if you can’t find a way to apply leverage in the negotiation, there is no negotiation. Leverage is the key to success in most negotiations. With leverage you can get a better deal, without it you are just another commodity. Physicians can obtain leverage in many ways: more training, excellent reputation, strength in numbers, careful use of … Continue reading
AHIP Releases Totally Bogus Survey of Physician Billed Charges
I use to hear the phrase ‘totally bogus’ all the time in the ‘80s, and when America’s Health Insurance Plans released a ‘Survey of Charges Billed by Out-of-Network Providers’; I knew I had come across the perfect example of a totally bogus piece of deliberately misleading health insurance industry propaganda. According to the survey summary: “for consumers who choose to seek care out-of-network, our latest survey shows that the charges billed by some out-of network … Continue reading
How Health Plans Avoid Paying for Emergency Care
Emergency care providers (emergency physicians and specialists on-call for the ER) are at a significant disadvantage when it comes to trying to get paid fairly for services rendered to enrollees of commercial health plans. Most other health care providers are able to: 1) screen prospective patients to make sure they will get paid appropriately for the care, 2) elect not to care for a plan’s enrollees, or participate in a health plan’s network, if the … Continue reading
Posted in Health Care Reform, Managed Care Contracting, Payment Reform
Tagged balance billing, Capitation, deferral of ED care, Emergency Care, emergency medicine, EMTALA, health plan contracts, Healthcare claims coding, Managed Care Contracting, medical screening evaluation, politics of health care
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