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True Cost of Limited Liability and High Deductible Plans November 6, 2009 PowerPoint Presentation
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True Cost of Limited Liability and High Deductible Plans November 6, 2009 - PowerPoint PPT Presentation


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True Cost of Limited Liability and High Deductible Plans November 6, 2009 Learning Objectives What is the long term viability and marketability of such products? What is the financial impact to participating providers? How should providers analyze risks of these products?

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Presentation Transcript
learning objectives
Learning Objectives
  • What is the long term viability and marketability of such products?
  • What is the financial impact to participating providers?
  • How should providers analyze risks of these products?
  • How effective are providers in tracking patients with these types of products?
  • Are there strategies for dealing with the growing volume of higher patient liability products?
discussion themes
Discussion Themes
  • Environment
  • Management
  • Contract
  • Process
  • Resolution
environment
Environment
  • Did limited liability and high deductibles benefit offerings exist ten years ago?
  • Has the volume of limited liability and high deductible accounts increased?
  • Is the volume of limited liability and high deductible accounts aligned with a certain product offering?
  • Are patient liabilities correlated with select services?
  • Do providers/payers see these products growing in the future?
management
Management
  • Is the role (scope) of contract team clearly defined?
  • Do you have objective contract performance metrics?
  • Do you typically get involved in collections and accounts receivable liquidation?
  • Is success a function of negotiation skills?
  • Has the financial impact of limited liability and high deductible offerings been quantified?
  • Is limited liability and high deductible offerings a top priority?
  • Have limited liability and high deductible offerings adversely impacted portfolio yield?
contract
Contract
  • Do your contracts restrict access based on product or benefit design?
  • Is there a correlation between benefit design and provider contract rates?
  • Are products and benefit design clearly defined?
  • Are there justifications for non-payment?
  • What are your top three contract language provisions?
process
Process
  • Are all payers mapped within financial system?
  • Is an accurate expected payment computed on each account?
  • Is patient liability segregated from insurance payable in patient accounting system?
  • Is there a prompt payment notification protocol?
  • Are payment discrepancies identified upon EOB receipt?
  • Is there a clear definition for limited liability and high deductible account tracking?
  • Are there processes in place to capture payment at time of service?
  • Are these product types changing the patient/provider relationship?
resolution
Resolution
  • Have you been successful in resolving payment issues with contract language amendments?
  • Are payers aware of the providers concerns?
  • Are payers able to resolve the patient liability collection shortcomings?
  • Have your ever provided the insurance company a patient specific report of delinquent patient accounts?
  • Does the employer/member subscription agreements require patient compliance as a term of participation?
  • Was the demand for limited liability and high deductible plans at the request of the member?
mental justifications
Mental Justifications
  • Product differentials
  • Audit
  • Offset
  • Administrative denials
  • Pre-certification requirements
  • Concurrent review
  • Incorrect coding
  • Poor documentation
strategic pricing or negotiation
Strategic Pricing or Negotiation
  • Population (Segmentation)
  • Groupings
    • Clinical (Severity)
    • Acute Care (Predictability)
    • Patient Direct Expenses (Volatility)
  • Efficiency (Correlation)
    • LOS
    • Technology
    • Patient Liability
    • Payment Logic
  • Effectiveness (Validation)