Special E-Mail Bulletin
August 2002
Texas DOI to require payers to reveal payment info
Special E-Mail Bulletin
Many of you have probably suffered with third party payers that refuse to include complete reimbursement information in your contracts. They'll claim the information is "proprietary."
Or, they'll downcode or bundle your claims and pay you less than expected. Then they refuse to explain their methodologies or justify the payment reductions -- you're just forced to live with it.
Well, in Texas that's about to change. The Department of Insurance there is releasing regulations that will require payers to disclose to physicians information on how they set their fees, including information on bundling and downcoding.
Hopefully this will be the start of a trend that spreads to other states.Clearly there is a need to hold payers accountable and for full disclosure prior to the signing of any managed care provider agreement.
This story is from the August 12 issue of AMNews.
Gil Weber
Texas wants insurers to say what they pay
The state's insurance department would require disclosures on fee schedules.
By Julie A. Jacob, AMNews staff. Aug. 12, 2002. Additional information
The Texas Dept. of Insurance will soon issue final regulations that will require insurers to disclose to physicians information on how they set their fees, including information on bundling and downcoding.
The insurance department developed the proposals in response to the Texas attorney general's ruling earlier this summer stating that it does have the authority to require insurers to reveal this information.
Teresa Devine, director of health care financing at the Texas Medical Assn., described the insurance department's development of the proposed regulations as "a significant victory for physicians."
"We have had a problem getting the most basic of information to determine whether or how a physician is going to be paid for a particular service," she said. "Insurers have told physicians that it is proprietary information and not to be disclosed."
No other states have similar regulations, according to the AMA Dept. of State Legislation. Other states are considering it, though, and the Supreme Court in Georgia has ruled that Blue Cross Blue Shield of Georgia must disclose its fee schedule
The Texas insurance department issued two proposed regulations in early June.
One proposal would require insurers to include information on all contracts about fee schedules, any nonstandard coding methods, bundling and downcoding policies.
The other, less stringent proposal would require insurers to provide physicians such information on request, within 30 days.
The TMA supports the more comprehensive proposal.
"The bottom line is to make sure that insurers share enough information with physicians and other providers so they can calculate what they can expect to be paid under their contracts," said Devine.
The Texas Assn. of Health Plans supports the more narrow proposal, said Leah Rummel, executive director of the Texas Assn. of Health Plans.
"Option one would be more onerous and ... basically, the health plan would have to stop operating," she said.
The health plans group "also asked for stronger provisions that will allow health plans to penalize physicians who disclose fee information to other physicians," Rummel said.
No date has been set for release of the final rule, said Lee Jones, an insurance department spokesman.
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