Last week I asked one of our pediatric clients how many plans they participated with.
Last week I asked one of our pediatric clients how many plans they participated with. My assumption was that they would count the number of companies that they have contracts with; however, each one of those companies has multiple plan types, each with differing rules and payment structures. They answered my question by counting the different plan names and also the number of different claims addresses in their practice management system.
The total number of plans was a staggering 584!
For a four-physician group, that amounts to a whole mountain of red tape.
Many practices have become accustomed to the rate “differentials” between HMO and PPO plans, as these have steadily increased over the years. But the market is changing rapidly. Consumer-directed health plan enrollment has grown 44 percent from 2007 to 2008, and more low-cost, bare-bones policies are being offered to younger people in the individual market. The reduced profit margins in these offerings are being passed along directly to physicians in the form of lower payments.
In addition to having to manage multiple fee schedules, there are also different rules associated with each plan: Does the plan require physician referrals; Is there coinsurance and/or deductibles associated with the plan; And what drugs are on the plan formulary, at which cost tier?
To illustrate my point, consider UnitedHealthcare’s plans in the New York area. There are different rates for each of its Oxford Freedom and Liberty plans, its AmeriChoice product, its Options PPO plan and other non-PPO plans, its Evercare and Secure Horizons plans, and its consumer-directed healthcare plan Definity. So what can you do to successfully manage all the different rules?
Start off by quantifying the list of plans for each payer with which you participate, and making sure your staff can easily access the information. Some payers make it easier than others to find plan information.
If you can’t find what you need on their Web sites, call the companies directly and ask them to provide you with a list of all their offerings and the details for each plan. And if the provider relations rep can’t help you, ask to be transferred to the sales department - those folks sell plans and should have information readily available to share with you.
Once you have the information you need, compile the information so that it can be accessed easily by both your billing staff and the front desk. We’ve provided an excel template to get you started.
However, don’t just use this information to better understand and manage the differences between payer plans. You will also want to capture the different fees associated with each plan, under each payer. Why? Because it’s important that you complain to your payers if you uncover payment discrepancies. You are providing the same services, delivering the same level of care, and paying the same costs to take care of each of their members, so why should you be paid less to provide care to some patients and not others?
Susanne Maddenis founder and CEO of The Verden Group, a consulting firm that helps physicians handle the complexity and volume of change in managed care today. She writes and speaks frequently on all aspects of managed care. She can be reached at firstname.lastname@example.org or by visiting www.theverdengroup.com.