Good Old Days. Along Came HMOs 6/8/2010. Out-of-Network Provider Status. Payers provided fair and adequate reimbursement

Transcription

1 Out-of-Network Provider Status Is it still an option? Thomas J. Pliura, M.D., J.D. June 2010 Ortho & Spine Conference Good Old Days Payers provided fair and adequate reimbursement Out of Network providers received U&C for their services In Network provider could potentially receive more patients Along Came HMOs Patients could not go out-of-network Unless they paid the bill HMO s fell into disfavor Patients did not like HMOs HMOs lost market penetration 1

2 Then Came PPOs Preferred Provider Organization Cross between choice and no choice Providers were free to join Could accept proposed reimbursement plan Sometimes could negotiate fees Patients could use out-of-network docs Had to pay differential E.g. 80%-20% versus 70%-30% vs 50%-50% Providers could discount fees to patients New Battle Front Health Plans developing weapons to try and prevent out-of-network utilization sell PPO product (higher premium), but only pay out HMO benefits Ignore the assignment of benefits for out-ofnetwork provider Send checks directly to patients ERISA may trump state laws A sneaky U&C definition Sneaky U&C definition Historically U & C could be supported with industry data (to help providers) New definition of Usual and Customary Sometimes Medicare rates, or less Arbitrarily defined U & C Examples 2

3 The Disparate Deductible In Network Deductible $200-$500 $5,000 out-of-network deductible Large deductible removes ability of provider to discount out-of-pocket payment Examples Pendulum Swings Nothing lasts forever Old days are long gone Pendulum beginning to swing back a bit Towards physicians and surgery center Away from Insurance companies It is too early to tell yet Leave it to the Lawyers Lawsuits starting to mount up New York Attorney General fights Ingenix and United HealthCare Numerous Challenges to health plans re out-of-network status 3

4 New York Attorney General Lawsuit based on flawed Ingenix data AG Andrew Cuomo pursued investigation Resulted in exposing Ingenix as flawed Will completely revise OON payment system data New data system forthcoming Tarzana Surgery Center Tarzana Surgery Center vs. United Health Group, Ingenix, et al Filed May 7, 2010 Federal Court in Los Angeles Based on OON underpayments Georgia ASCs v. Blue Cross Class Action against Blue Cross Based on Out-of-Network underpayments Allegations: Blue Cross cut OON payments by 80% 4

5 Crain s Chicago Business News Blue Cross Monopoly Power in Chicago May, 17, 2010 Paints negative picture of Blue Cross 30% rate hikes Health insurer monopoly power sound bite Presbyterian-Novant vs Aetna Lawsuit filed by Hospital Alleges Aetna made False statements Misleading statements Threatens OON status for patients Legal Case Blue Cross and Blue Shield of Louisiana vs. RAPIDES HEALTHCARE SYSTEM 5

6 RAPIDES HEALTHCARE SYSTEM Louisiana's assignment statute not preempted by ERISA Blue Cross could not legally send payment to patients State law prohibited Blue Cross from sending checks to patients Strategies Become involved in Community Do not underestimate this strategy Chamber of Commerce Get involved in network of employers Obtain copy of Plan Benefits Know what the plan says What is definition of U & C in plan booklet Document, document, document Can You Remain Out-of-Network Are you the only game in town What is your competition How much of your business is disparate deductible 6

7 Has Balance of Power Shifted? Can Providers afford to remain out of network It Depends What is the discount being demanded How is U & C defined in the benefits book Are carriers in your area employing disparate deductibles 7