E-Mail Bulletin #1, May 1998
Contents
1) Tired Of Slow Claims Payments From HMOs? Help Is On The Way
2) Continuous Quality Improvement: Working With Healthplans
3) Medicare Risk HMO Enrollment Trends
1) Tired Of Slow Claims Payments From HMOs? Help Is On The Way.
Everyone understands that compensation under managed care is not going to match that received from your private pay patients. There's a trade-off
volume for discounts. In most situations the incremental patients and revenues work to the practice's benefit, particularly when the plan pays in 30-45 days. But when the healthplan is consistently late processing your claims, and payments drag out 90, 120, 150 days or more, that certainly changes the equation.
Even a paragraph in your provider agreement obligating the plan to pay within a certain number of days does little good if you don't have the leverage to enforce it. Since few have the financial resources to seek legal redress against an HMO, healthplans typically feel no meaningful pressure to meet their contractual obligations. And the plans know that Departments of Insurance do not usually put this issue high up on their priority totem poles.
But the problem has gotten so bad in some states and with some payors (e.g., the recent problems with Oxford Healthplans) that state legislators are now stepping in on the provider side. New York and Texas are but two of several states that have recently initiated changes to their insurance laws requiring HMOs to pay claims promptly. Many other states are or will initiate similar changes soon, so some help is on the way.
New York's law requires that plans pay "clean" claims within 45 days of receipt or face fines of up to $500 per claim per day. Texas places the same 45 day requirement on its plans. Typically, the new laws also require that plans pay the "clean" portion of any claim even if a part of that claim is in dispute (i.e., plans cannot deny/delay payment on an entire claim for a minor discrepancy in one portion). Responsibility for monitoring compliance falls to each state's Department of Insurance, and some have gone so far as to set up toll-free hot lines where providers can report compliance problems (e.g., New York's number is 1-800-358-9260).
Hopefully we'll see these departments a lot more responsive to provider complaints now that the legislatures have given clear directives to enforce the law.
I recommend that you determine if your state has such a law in place or under development. There are some simple ways to find out: 1) Call your state society office and speak with the legislative staff liaison. 2) Call your state's Department of Insurance and speak with someone in the HMO regulatory section. You should be able to request a copy of the relevant language, if enacted. I've even heard of some situations where one could obtain copies of pending legislation.
Use this knowledge and the power of state law if you're having payment problems with an HMO. Since plans don't want to run afoul of regulators, a call or letter to the plan's Claims or Provider Relations Director citing the law should suffice. But if it does not, then use the state
Department of Insurance as your leverage
file a formal complaint (with a copy to your congressional representative). But be certain that you have excellent documentation of your calls and letters to the plan and, obviously, the dates the late claims were filed in order to demonstrate that the plan is out of compliance.
2) Continuous Quality Improvement: Working With Healthplans
There's lots of talk these days from the payor community about the importance of quality
total quality improvement and continuous quality improvement. To many of us that's little more than lip-service. We've seen too many examples where a plan talked a good story but brought little to the table when it came to working cooperatively and creatively with the providers. If you've been frustrated in efforts to implement or demonstrate meaningful quality assurance and quality improvement programs, then you might want to obtain a copy of a very interesting report.
"Implementing Guidelines for Eye Care of Diabetic Patients: Results from an HMO Intervention Study" appears in the American Journal of Managed Care, Volume II, No. 4, April 1996, pp. 365-369. (see also from the same issue pp. 452-454, an editorial, "Improved Screening for Diabetic Eye Disease: How a Managed Care Plan Helped.")
Quoting from the abstract: "The objective of this study was to determine the frequency with which diabetic patients 18 years or older enrolled in a health maintenance organization received dilated retinal eye examinations, and whether an intervention strategy could increase that frequency...This study demonstrates how a health maintenance organization database can be used to identify at-risk populations, and to improve the compliance of these populations with evidence-based medical guidelines."
The article describes the methodology and working relationship between the doctors and plan (in this case, US Healthcare). It's an interesting piece and can certainly be used as a springboard for developing similar programs in your local community.
You can reach the Journal at: 1816 Englishtown Road, Suite 101, Old Bridge, NJ 08857, or by phone at: (732) 251-8361.
3) Medicare Risk HMO Enrollment Trends
Medicare Risk HMOs continue to grow at astonishing rates, and the numbers are changing fastest in some markets that until recently had little or no experience with senior HMO products. A new (almost free) report provides some startling information you'll want to have.
"Medicare Risk Enrollment: Emerging Market Trends You Can't Afford to Miss" is available from the Managed Care Information Center, Dept. 14MedRisk, PO Box 456, Allenwood, NJ. 08720. Include a self-addressed 9X12 envelope with $.78 prepaid postage.
A few selected statistics from this excellent report:
The 1997 average enrollment growth into Medicare Risk healthplans across HCFA's 10 regions was 37.96%. The Boston region had the greatest growth (68.8%).
Ohio had the greatest percentage increase by individual state (140.8%) while Pennsylvania had the greatest increase in number of new enrollees (120,715).
Incredibly, the nation's five largest Medicare Risk HMOs (representing only 1.6% of all Medicare Risk HMOs) hold more than 20% of the nation's total senior HMO population. Not surprisingly four of those plans are in California and the fifth is in Florida. But the growth in new plans is most pronounced in smaller markets. That's a very important trend to watch this year.
That's all for this first managed care e-mail bulletin. I hope you've found it interesting and that you utilize the resources I've highlighted.
Please also tell your friends and colleagues about my website so that they can visit and sign-up.
Your comments and questions are always welcome, as are inquiries about specific projects or issues involving your practice, group, or network.
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