More than 300,000 physicians and other eligible professionals have signed up to participate in the federal electronic health-record system incentive payment programs, while more than 4,000 hospitals have enrolled in the Medicare EHR incentive program, the Medicaid incentive program or both, according to the latest CMS data.

In total, $7.7 billion has been paid out in what has been estimated will be $27 billion in incentive payments through the lives of the two programs. The increase to 303,072 enrolled physicians and other eligible professionals, is listed in the CMS' report through September.

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While prohibitions against balance billing have been around for more than a decade, many healthcare providers still don’t understand their rights when it comes to collecting payment from patients and third-party payors.

Insurance companies often have predetermined rates they pay to non-contracted healthcare providers, but they don’t always reflect what is written in the member’s contract. As a result, providers end up being underpaid if they don’t have a written contract with the payor.

This is of particular significance to emergency care providers. Why? Because ER doctors and hospitals must, by law, provide emergency care without regard to whether the patient has the ability to pay.

After providing emergency care, medical providers often question the payment obligations under the patient’s Health Maintenance Organization or health insurance contract. If the emergency medical provider has a direct written contract, the reimbursement is governed by that participating provider contract’s reimbursement terms. 

However, when there is no direct, written contractual relationship, what are the insurance company’s payment obligations for emergency services and the legal underpinnings for those obligations?  State and federal laws mandate that emergency medical providers offer services without regard to payment.

In Florida, the HMO’s payment to a non-contracted provider of emergency services is governed by Florida Statute §641.513. This statute mandates that a non-contracted provider of emergency services is entitled to reimbursement for services provided to a HMO member at the lesser of the charge “mutually agreed” upon, the provider’s charges, or the usual and customary provider charges for similar services in the community where the services were provided.

Often, the HMO will pay the non-contracted medical provider of emergency services what it has determined to be the “usual and customary provider charges for similar services in the community where the services were provided.” Many HMO’s use a blended rate based on the Medicare fee schedule, the HMO’s internal calculations, or data purchased from a third-party vendor (such as Ingenix). This approach does not result in a fair analysis as to what is the usual and customary rate in the community, resulting in underpayment to the emergency medical provider.  

Florida Statute §641.3154 prevents the emergency service provider from balance billing (or billing the patient) when there is a dispute with respect to the sufficiency of the HMO’s payment for the emergency services. This means any collection efforts (aside from applicable co-payments and deductibles) for underpayment of emergency services must be directed at the HMO.  As a result, if an emergency service provider is dissatisfied with amount of payment received for the provision of emergency services and care to an HMO patient, the emergency medical provider’s sole recourse is against the HMO.

When the patient is covered by a health insurance contract instead of an HMO contract, the analysis changes. Florida Statute §641.513 does not apply to health insurance contracts, only to HMOs. A health insurance company is only obligated to pay what the terms of its contract dictates that it will pay. This does not mean a health insurance company can pay whatever it wants. It must strictly follow the terms of the contract. Vague and ambiguous language will be construed against the health insurance company.  Unlike HMO members, patients who are insured under a health insurance contract may be billed the remaining portion should a payment dispute occur. As a result, health insurance companies have a duty to pay the correct amount to medical providers on behalf of their insured. If they fail to pay emergency claims correctly, they expose patients to collection actions, and thus higher payments for medical bills. 

Many health insurance companies have decided that a certain percentage of the Medicare allowable is usual and customary, a fair allowed amount, or a maximum allowable payment under the contract.  Often, these payments do not withstand scrutiny if challenged properly and the HMO must make the payments it owes.

Bradley M. Seldin, Esq., is an attorney at the Florida Health Law Center in Davie, Fla. The firm specializes in all areas of healthcare law including fraud and abuse, bioethics, healthcare business transactions, HIPAA, compliance programs, pharmaceutical, managed care, clinical trials, medical staff issues, contracting and licensure issues.

With commentary from Richard Lucibella and Michael Casanova

When we were preparing for our October 16 Healthcare Roundtable Event entitled Preparing for Paradigm Shift in Physician Compensation, I was doing a lot of research on ACO's. One article published in Health Affairs recently had a worrisome theme: A Simulation Shows Limited Savings From Meeting Quality Targets Under The Medicare Shared Savings Program. With so much hope and hard work plus human capital and financial resources devoted to the ACO model, this was a disheartening conclusion. I had an opportunity to get some feedback from Richard J. Lucibella of Primus Health Network, LLC. Based in Palm Beach County, Mr. Lucibella and his team have recently launched an ACO. I also ran it by Michael Casanova, Senior Healthcare Consultant, Strategic Consulting Services. Based in Miami-Dade, Mr. Casanova is a consultant with vast experience in the health industry including C-level positions at Jackson Health Systems and Surgical Park.
 
Here is what Richard had to say:

"I thank you for the link to the study and the offer to respond. I suspect this study is partially correct but hardly definitive:

For example, they assume more visits to manage the diabetic condition; but if these visits were in the context of a primary care "blitz" to get control of the totality of patient care, much more is going on during those encounters than just diabetes measurement.  Thus, measuring diabetes-only related cost reductions would not result in a very robust model. It's sort of the obverse of what politicians do when they project 1 variable absent the unforeseen consequences of the actions that are acting on that variable.

Even a meager 10% improvement in diabetic performance measures will be accompanied by closer primary care control of the plan of care and fewer specialist interventions provided in a vacuum. Their model fails to account for the ripple effects of that dynamic on iatrogenic events and admissions (for one).

Next, I don't consider a 10% improvement in performance acceptable by any means. We know who the patients are; they're selected by their 3 year "loyalty" to our primary care physicians; we have their claims histories; and we have our eye on the performance measures.

So, in the end, what if the study is a bit off and the real savings is more like 3% due to the diabetic focus? We'd probably admit that was within the study's margin of error, yes? What if another 2-3% is generated by CHF initiatives and another point or two by reducing the  rate of 30-day readmissions thru aggressive discharge follow up (to name 2). In the end, what if we "only" decrease costs by 8-10%, in total? I call that the first step toward a raging success.

I'm not arguing the Shared Savings program will be that raging success from the starting gate. But I do know that performance measures for common chronic conditions allow physicians to focus on the actual plan of care, rather than the immediately billable Chief Complaint. The focus changes the physician practice and the physician-patient relationship for the better in comparison to the model we've hung on to these past 50 years. I doubt the ACO program is the Holy Grail of Medicare costs; but Pay-for-Performance is a concept whose time has come and the Shared Savings program is, if nothing else, a step in the right direction."

Mr. Casanova was more concise and also (somewhat) hopeful. Here is what Michael had to say:

"I agree with these findings. Real sustainable cost savings will be achieved by coordination and administration assuming a flat line for morbidity."

So the jury is still out. And there is still some reason for optimism with regard to the ACO model. Let's keep our fingers crossed; it's in everyone's best interest if we can bend the cost curve.

Are you completely happy with your current job? If not, now is a great time to analyze your job satisfaction. There are ten sure signs that you are experiencing job dissatisfaction. If you:

1.             Dread Mondays or coming to work

2.             Can’t wait for Friday

3.             Are often bored at work

4.             Feel tired or chronically fatigued

5.             Avoid your boss and dread meetings

6.             Have no enthusiasm or sense of self-worth

7.             Feel like you are getting nowhere in your job

8.             Take work stress home

9.             Question your choice of industry or occupation

10.          Can’t think of a way out

Any of the above signs indicate a need for change. The biggest career mistake is to ignore those indicators. A head-in-the-sand mentality can lead to a downward career spiral that ends with disappointment and “what if” regrets.  Here are three great ways to facilitate positive change.

• Analyze your career choice.

Is the problem your boss or employer—or is it that you have chosen the wrong occupation? Before you take any action, make sure you know what needs to change.  Don’t make the mistake of throwing away a good career (ex. accounting, sales, finance) when the problem is really the person you work for. On the flip side, if you’re not cut out for sales, then changing employers isn’t going to help the problem.  A career coach can guide you to determine which of these problems is causing your unhappiness and give you ideas for your next career move.

• Update your resume.

Updating your resume can give you a great confidence boost. You’ll feel better immediately if you know you are ready whenever opportunity knocks.  Be careful, however, that your resume doesn’t resemble a house with too many additions, each resembling a different style. If you have simply added to the same old resume job after job, it’s time to “tear down that old shack” and rebuild your resume from the ground up.  If your old resume format doesn’t live up to your professional image, you may want to consult a resume coach. You’d never wrap a ruby ring in old newspaper, and you should never present your career with anything less than professional polish.

•  Brush up your interview skills.

If you have been on the job for a couple of years, your interview skills are probably rusty. Don’t make the mistake of blowing off the first few interviews as practice. They might be the perfect jobs for you!  You’ll feel much more confident and comfortable if your interview skills are honed before you step into the first interview. To determine your current level of interview expertise, answer the following questions:

·         Do you know the toughest interview questions—and how to answer them?

·         Can you answer the salary question without compromising the level of starting salary at offer time?

·         Can you recognize the most common interview styles—and respond without showing stress?

If you aren’t sure, then it may be time to visit with a career coach who can help you prepare to WOW them in every interview.

Job dissatisfaction is an indication of needed change. Take the steps of change by investing in the appropriate job-search skills and tools, and you will be in a position to change your job—and your life—for the better.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Deborah Walker, Certified Career Management Coach

Read more career tips and see sample resumes at:  www.AlphaAdvantage.com

email: Deb@Alphaadvantage.com

360-260-4965

Twitter: http://twitter.com/DebWalkerCCMC