Posts

How Your Payer Directory Profile May Harm Your Practice

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March 15, 2017 | Payers, Contracts, Patients, Pearls

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Original published at www.physicianspractice.com

Are you aware that insurance companies are ‘grading’ you? Do you know what your grade is? Do you understand how your profile can impact your patients, particularly if your score is not enough to make ‘top tier’? If you don’t, now is the time to pay attention to this issue.

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Physicians Contract with Self-Funded Employers

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Pearl | October 28, 2015 | Payers, Patients, Pearls, Physician Compensation, Revenue Cycle Management

By Susanne Madden

Originally published at: http://www.physicianspractice.com/payers/physicians-contract-self-funded-employers

Some medical practices are cutting out insurance companies and providing services directly to employers (direct care), thereby reducing overhead and cost to patients.

First, let me define what is meant by “direct care.” Similar to charging patients cash for your services, the difference here is that you are charging employers directly for services delivered to their employees. There is no middle-man insurance company; simply two parties exchanging cash for services. So “direct” here means that you, the physician, are selling your services directly to the purchaser of healthcare, the employer.

This is not as novel an approach as you might think. Employers, particularly those that are “self-funded” (meaning those that carry the financial risk for employee claims rather than the insurance company), have already been investing in medical tourism for years. They contract directly with providers of care overseas (or through medical tourism companies) and send employees for such services as bariatric surgery, knee and hip replacements, and hernia operations, which are far less expensive than here in the United States. Even some insurers, like Anthem Blue Cross and Blue Shield, are exploring the idea of including medical tourism as a part of their coverage.

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Participating in New Healthcare Exchange Plans

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Pearl | February 19, 2014 |
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It is early with regard to the healthcare exchange plans and yet practices across the country are already feeling the impact. It’s not just consumers who have experienced problems while attempting to sign up for the exchange plans on the healthcare.gov website; providers too are dealing with major headaches as they navigate through the first couple of months of this new system.

Looking for more information about the effects of healthcare reform on your medical practice? Join us May 2 & 3 in Newport Beach, Calif., for Practice Rx, a new conference for physicians and office administrators.

Let me explain. The insurance companies created something called “narrow networks” within their full network of providers. What that means is that only a subset of physicians within any given insurance company’s network “qualified” for participation in the exchange plans. The result is that while some physicians got rolled into these plans, others were excluded, even though they participate in some of the other products with that particular insurance company. For example, a physician could be participating with an HMO and a PPO-type product, but be excluded from the exchange product. This has created a dilemma for many practices. On the one hand, it means no new business coming in from new exchange members. On the other hand, it also means scrambling to hold onto existing patients that have switched to these new, lower-priced health insurance products.

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