Oxford has notified several New York physicians of a change from 'charge-based' insurance reimbursement (including the fraudulent UCR) to 'fee-schedule' based out of network reimbursement.
According to the notification, out of network reimbursement will be limited to an amount of 140% of the published medicare reimbursement amount.
We first learned about the program, as applied to physicians, in an article which appeared in MSSNY News of New York, October 2009. In the article, Sanford P. Cohen, Chief Regional Medical Officer, UnitedHealthcare explained that the MNRP payment would be an option that could be elected by an employer. Cohen said that it 'will be based on 110% of the current year payments stipulated for Medicare patients by the Center for Medicare & Medicaid Services (CMS)'.
The schedule-based MNRP program was implemented in New Jersey in January 2009. At the time it applied to Hospitals (inpatient and outpatient), Free-standing ambulatory surgery centers, Free-standing radiology centers, and Free-standing laboratories.
Among the stated goals of the program is the promotion of provider participation and consumer choice. But this is a dangerous and anti-competitive precedent. If allowed, this program:
- Harms Physicians - it further reduces a plan's incentive to negotiate with participating physicians, as an insurer's exposure is limited, irrespective of whether a physician is in network or out of network.
- Harms Consumers/Patients - it strips much of the value from an out of network benefit, a benefit that 70% of insureds currently pay extra premium for.
Link to Oxford Materials:
FD writes:
ReplyDeleteThis is dangerous, and perhaps smart. Portray 110% of Medicare as "generous" when Medicare fees are supposed to be discounted compared to true UCR, and have been stagnant for 15 years, and will drop by over 20% in a few weeks, thus lowering th4e Oxford fees to aout 90% of the current medicare fees.
As a consumer/patient, who will be paying over 1500/month for my family's health insurance starting january 1, I will be outraged of GHI does such a thing with my out of network benefit. This benefit becomes essentially useless, and would pit me against my doctor if I didn't understand what they are doing to me.
Does this violate the letter or spirit of the class action suits/settlements that MSSNY and AMA have been working on?
These guys are clearly their own worst enemies.
ReplyDeleteSenate reform loophole allows caps on payouts for some illnesses.
ReplyDeleteThe current version of the Senate Democrats' healthcare bill lets insurance companies place annual limits on the dollar value of medical care, as long as they are not "unreasonable." The term isn't defined, however, which obviously gives insurers a great deal of latitude. The bill still bans lifetime limits on the dollar value of coverage, but critics say that if annual limits are allowed, the lack of lifetime limits will be all but neutered.
Groups backing care for costly diseases like cancer--treatment for which can rise above $100,000 per year--told the Associated Press that they were blindsided. "We don't know who put [the provision] in, or why it was put in," said Stephen Finan, a policy expert with the American Cancer Society Cancer Action Network's advocacy affiliate.