previous payments made on the patient’s behalf to doctors, hospitals, and other health care providers.
The 2009 congressional investigation into the rescission practices of just three large insurers revealed that they had rescinded nearly 20,000 policies over a five-year period. Rescinding those policies allowed the companies to avoid paying $300 million in claims for life-saving medical care.102
When members of Congress
asked insurance executives if they would end the practice of rescission when a person makes an innocent mistake, they said they would not. That’s because dumping even a small number of enrollees can have a big positive effect on the bottom line. TMA supports the appropriate use of rescission as a response to true fraud; however, the legislature needs to prohibit and address the “gotcha” approach that leads to inappropriate rescissions by insurers.
Some insurers also wrongfully dump small groups by “purging” a group when its medical claims turn out to be larger than what the insurers’ underwriters projected. The purging of less profitable accounts through unjustified premium increases may explain why the number of small businesses offering coverage to their employees has fallen from 61 percent in 1993 to 38 percent in 2009, according to the National Small Business Association.103
Promote real-time claims payment Once medical claims are submitted for payment, insurers may take weeks before they finalize the claims and approve them for payment. Patients often are surprised by the amount they owe toward the remaining portion of a medical bill. Patients’ surprise is typically rooted in their policies’ copayment, coinsurance, and deductible requirements. Most physicians are unable to discuss actual payment information with patients because they don’t have real-time claims access to the patient’s current benefit status.
Instant health insurance claims processing offers a solution to these problems. A fully adjudicated claim in real time permits patients to know exactly
58 TEXAS MEDICINE February 2013
how much they owe at the time they receive services.
Physicians also would have the information necessary to fully inform patients on what they owe. Instant health insurance claims processing reduces the chance a patient will receive a surprise bill weeks after receiving care.
Promote direct patient-physician payment options for business health care plans
Consumer-directed health care plans offer a promising option for improving efficiency by eliminating the insurance company from financing a large portion of routine health care services. Under these plans, businesses establish high- deductible insurance plans for their employees, coupled with accounts that employees can use to cover their family’s routine medical expenses with pre-tax dollars.
This approach improves efficiency if these plans bypass the usual process of submitting formal medical claims to insurance companies and waiting for lengthy review and payment. It strengthens the practices of primary care physicians who are particularly overburdened by the health plans’ demands that every small service pass through their scrutiny. To the employer, the employee, and the physician, the value of consumer-directed health plans lies in their simplicity.
To be successful, these accounts should be seeded with initial funds and allowed to grow with tax- free employee savings that roll over from year to year. Benefits should promote employees’ use of preventive health care services, such as cancer screenings, immunizations, and prenatal care. Administrative overhead should be minimized through the use of debit cards or other methods that limit transaction costs for all parties.
Promote fair contracting practices by government and private payers Because of the imbalance in negotiating power between physicians and large insurance companies, and non-existent negotiation with government
Page 1 |
Page 2 |
Page 3 |
Page 4 |
Page 5 |
Page 6 |
Page 7 |
Page 8 |
Page 9 |
Page 10 |
Page 11 |
Page 12 |
Page 13 |
Page 14 |
Page 15 |
Page 16 |
Page 17 |
Page 18 |
Page 19 |
Page 20 |
Page 21 |
Page 22 |
Page 23 |
Page 24 |
Page 25 |
Page 26 |
Page 27 |
Page 28 |
Page 29 |
Page 30 |
Page 31 |
Page 32 |
Page 33 |
Page 34 |
Page 35 |
Page 36 |
Page 37 |
Page 38 |
Page 39 |
Page 40 |
Page 41 |
Page 42 |
Page 43 |
Page 44 |
Page 45 |
Page 46 |
Page 47 |
Page 48 |
Page 49 |
Page 50 |
Page 51 |
Page 52 |
Page 53 |
Page 54 |
Page 55 |
Page 56 |
Page 57 |
Page 58 |
Page 59 |
Page 60 |
Page 61 |
Page 62 |
Page 63 |
Page 64 |
Page 65 |
Page 66 |
Page 67 |
Page 68