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Many Changes Coming for Private Payers


Keeping up with the changes in the insurance industry right now is like herding cats. Here's what is on the horizon.

Well, it's certainly been an interesting week with payers making very big decisions that can affect a practice's bottom line in a big way.

Just a few days ago, Blue Shield of California CEO Paul Markovich, announced that he will be not only closing the company the entire week of Labor Day, but that he is requiring his staff to use their personal vacation time during this closure. He claims the closure is to reduce payroll-related liabilities claiming losses in the ACA exchange plans.

It's a very interesting business move that has undertones of just holding on to physicians' payments and raking in and banking the interest on those funds. This move could save Blue Shield $4 billion dollars, while physicians have to wait for their payments. I don't know about you, but when I go away on vacation and there is no one there to cover my tasks, they build up. Can you imagine what all of these backed-up claims will do to payments to providers? Just another delay tactic, if you ask me.

In a related story, Aetna is really swinging at the hornets' nest with its declaration that they will pull out of most of the ACA exchanges. United Health Care said last month that they will pull out of most of those markets, and Humana is considering pulling back as well. The Aetna statement seems to be motivated by its proposed merger with Humana, which is now looking at a court date in December with the DOJ. Aetna's CEO Mark Bertolini warned the DOJ back in July that if it delayed or derailed the merger with Humana his company would pull out of the exchanges.

On another note, Cigna is looking at Plan B if the Anthem/Cigna merger is nixed. CEO David Cordani of Cigna stated his company would offer investors stock buyback and capital deployment if the deal does not go through.

With all of these changes coming, physicians will, of course, be unsure of the direct effect on their practices. My advice is be sure you have a surplus of operating funds built up. Now would be a great time to spend some time working on the 90+ days in A/R category. There significant revenue tied up in those delays and denials that really wouldn't take a lot of time to resubmit to the insurance company. In fact, over the past three months, our billing department has been able to bring in 23.2 percent of the total cash inflow in the 90+ days in A/R category. It's very worth the time spent.

With the elections on the horizon, and the original ACA plans and exchanges built on a house of cards, it appears that the insurance industry is in a large flux, and shows no sign of slowing down. Be very aware and keep reading up on these types of situations so you know what might be coming down the pipeline for your practice.

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