Health Plan Payment and Reimbursement
Ask the Experts: Managed Care Contracting Benchmarks
August 14, 2017
10:29 am
I know that our state Department of Insurance is one organization that handles insurance disputes, as long as the employer is not self insured. Do you know of other avenues that we can pursue to resolve health plan payment issues? Does this vary by state?
Answer 1: It may vary by state. In New York, we go to the Department of Labor.
This question was answered by: Kelly McGinnis, FHFMA, director of revenue cycle, HealthAlliance of the Hudson Valley, and a member of HFMA’s Hudson Valley New York Chapter.
Answer 2: State associations are a good resource as well, and if other providers in the state are experiencing similar issues they can bring all complaints together to meet with the health plan.
This question was answered by: Suzanne Lestina, FHFMA, CPC, vice president, client innovation, AvadyneHealth, and a member of HFMA’s First Illinois Chapter.
Answer 3: I second Suzanne’s comments. For years in Florida, I was a member of a Florida Hospital Association revenue cycle committee. We met quarterly, wrote position papers, gathered data on statewide problems, and advocated with legislators.
This question was answered by: David Hammer, FHFMA, CHFP, principal at Healthcare Performance Management Consultants, and a member of HFMA’s Florida Chapter.
Answer 4: I would agree with Suzanne’s recommendation. I work for the Illinois Health and Hospital Association and we have quarterly meetings with our managed care forum, roughly 25 hospitals made up of managed care professionals. Because we aren’t allowed to discuss pricing, our focus is on identifying core health plan issues and determining the best advocacy or policy approach, which may include direct meetings with the health plan. The Hospital Association of New York also has a very active group as well in dealing with insurance issues.
This question was answered by: Paula Dillon, director of managed care, Illinois Hospital Association, and a member of HFMA’s First Illinois Chapter.
Answer 5: I agree with using your state hospital associations. I have the pleasure of working in Maryland, and the Maryland Hospital Association is a wonderful advocate for hospitals. We had regular individual meetings with our state Medicaid representatives, Medicare, and commercial health plans. It was a great way to share common issues and solutions to what we were all experiencing. We all participated in metrics reporting as well related to revenue cycle performance —think HFMA’s MAP App but on a smaller scale—but it certainly helped performance improvement when you were reporting your accounts receivable days statewide. We also worked very closely with the state insurance commissioner, inviting representatives to meetings quite often to speak on various topics.
This question was answered by: Christine Fontaine, CHFP, CPAM, senior director, revenue cycle optimization, Connance, and a member of HFMA’s Maryland Chapter.
Answer 6: I also agree. Each state has its own regulations and the authority may reside in different governmental agencies that govern insurance.
This question was answered by: David A. Williams, FHFMA, CPA, partner, Horne LLP, and a member of HFMA’s Mississippi Chapter.
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