Subscribe
Intelligence Unit
Special Reports
Special Events
Sponsored
Departments
- Leadership
- Finance
- Technology
- Physicians
- Community Hospitals
- Health Plans
- Marketing
- Quality
- Nursing
- HR
Follow Us
Payors may release incomplete data, convince savvy consumers to go elsewhere
Managed Care Contracting and Reimbursement Advisor, October 23, 2006
Hospital executives might think that you are the only one publicizing their rates as a response to the trendy rush of savvy consumerism. However, be aware that payors may also spread pricing data without consent.
Some payors are now jumping on board this public relations roller coaster, slipping disclosure clauses into provider agreements, and boldly displaying hospital pricing data without the benefit of patient education. As a provider, hospital leaders know the danger that this may pose when incomplete information reaches the consumer.
One deli’s turkey sandwich may cost twice as much as the competitor’s around the block, but if the consumer doesn’t know that the deli’s price includes all the fixings, then it could be out of business in a hurry.
Don’t be caught off guard. Engage in discussions with your managed care contractors and fight to make sure that payors only release accurate numbers, says Robin Fisk, Esq., an attorney from Ashland, N.H. “You don’t want to be surprised,” she says. “If you’re not prepared, then suddenly [payors] are publishing something that puts you in a light that you didn’t think was accurate.”
Evolution of the problem; next generation steps
Beware of broad terms about what the payor may publish, such as “Provider agrees to be included in our online and paper provider listings.”
“That used to mean your name and contact information, and you’d want that published,” says Fisk. “Now it could mean something much different.”
These terms initially mean that it’s time that the contracting negotiations include a frank discussion with the payor about what products it offers and what information it plans to make available to enrollees.
If the payor is compiling its own data, ask where it gets the data. Are they from a Web site, a state hospital association, or CMS? Or, is the payor creating them?
Perhaps the payor is basing its rankings on the hospital’s own coded claims. If so, ask whether you’re including all of the information to make the payor’s picture of the organization as accurate as possible.
“If you come out on top of the quality rankings and you’re coding your claims as completely as possible, then maybe you really are the stellar provider in your community, and patients should take this into consideration,” says Fisk. “But when the data [are] assembled by someone else and they are responsible for making decisions about what is included and how they rank, you must make sure that [they are] accurate.”
How about an explanation?
Your pricing data may eventually become public. If you remain competitive in your market, this doesn’t have to be a bad thing. But educating the public about where you derive your costs—although it’s a tall order—is a necessary evil. “The price could be the price for a straightforward procedure, but he or she might not be a straightforward patient and may have lots of complications,” says Fisk. “They’re going to look at costs and ask you why you are billing them some crazy amount. They’re going to feel ripped off by the provider.”
In its recent price transparency pilot, Aetna executives allowed some physicians to critique the payors’ materials explaining their prices.
How to take ‘no’ for an answer
Involuntary pricing transparency isn’t just a concern of managed care professionals who negotiate contracts with payors. The release of inaccurate data could have a ripple effect on the entire organization, beginning in the patient access area. The following questions should be considered:
Depending on how much leverage you have in the marketplace, the payor may or may not take your requests seriously. As an organization, you should talk about a different strategy or discuss how you’re going to react to this information. “This is also very much about public relations and patient education,” says Fisk.
This story first appeared in the October edition of Patient Access Advisor, a monthly newsletter by HCPro Inc. For information on all of HCPro’s products, visit www.hcmarketplace.com.
Some payors are now jumping on board this public relations roller coaster, slipping disclosure clauses into provider agreements, and boldly displaying hospital pricing data without the benefit of patient education. As a provider, hospital leaders know the danger that this may pose when incomplete information reaches the consumer.
One deli’s turkey sandwich may cost twice as much as the competitor’s around the block, but if the consumer doesn’t know that the deli’s price includes all the fixings, then it could be out of business in a hurry.
Don’t be caught off guard. Engage in discussions with your managed care contractors and fight to make sure that payors only release accurate numbers, says Robin Fisk, Esq., an attorney from Ashland, N.H. “You don’t want to be surprised,” she says. “If you’re not prepared, then suddenly [payors] are publishing something that puts you in a light that you didn’t think was accurate.”
Evolution of the problem; next generation steps
Beware of broad terms about what the payor may publish, such as “Provider agrees to be included in our online and paper provider listings.”
“That used to mean your name and contact information, and you’d want that published,” says Fisk. “Now it could mean something much different.”
These terms initially mean that it’s time that the contracting negotiations include a frank discussion with the payor about what products it offers and what information it plans to make available to enrollees.
If the payor is compiling its own data, ask where it gets the data. Are they from a Web site, a state hospital association, or CMS? Or, is the payor creating them?
Perhaps the payor is basing its rankings on the hospital’s own coded claims. If so, ask whether you’re including all of the information to make the payor’s picture of the organization as accurate as possible.
“If you come out on top of the quality rankings and you’re coding your claims as completely as possible, then maybe you really are the stellar provider in your community, and patients should take this into consideration,” says Fisk. “But when the data [are] assembled by someone else and they are responsible for making decisions about what is included and how they rank, you must make sure that [they are] accurate.”
How about an explanation?
Your pricing data may eventually become public. If you remain competitive in your market, this doesn’t have to be a bad thing. But educating the public about where you derive your costs—although it’s a tall order—is a necessary evil. “The price could be the price for a straightforward procedure, but he or she might not be a straightforward patient and may have lots of complications,” says Fisk. “They’re going to look at costs and ask you why you are billing them some crazy amount. They’re going to feel ripped off by the provider.”
In its recent price transparency pilot, Aetna executives allowed some physicians to critique the payors’ materials explaining their prices.
How to take ‘no’ for an answer
Involuntary pricing transparency isn’t just a concern of managed care professionals who negotiate contracts with payors. The release of inaccurate data could have a ripple effect on the entire organization, beginning in the patient access area. The following questions should be considered:
- Does your contract expressly state that your rates are confidential and prohibited from release without your approval?
- If the payor uses information from an external collection point, and you have an opportunity to review and appeal any inaccurate data, ask that the payor include only the finalized data in its reports about you.
- Include a clause in your contract that gives you advance notice of the data that the payor gathers and reports that it publishes, as well as the right to review and correct any inaccurate information concerning you.
- Ask for the ability to review and comment on any explanatory materials that accompany the data.
- Consider publishing your own explanation of the information that the payor makes available, explaining its significance and context.
- If you have enough leverage with the payor, consider a “reverse gag” clause that prohibits any action on the part of the payor that steers or would have the effect of steering patients away from you for those payor products in which you participate.
Depending on how much leverage you have in the marketplace, the payor may or may not take your requests seriously. As an organization, you should talk about a different strategy or discuss how you’re going to react to this information. “This is also very much about public relations and patient education,” says Fisk.
This story first appeared in the October edition of Patient Access Advisor, a monthly newsletter by HCPro Inc. For information on all of HCPro’s products, visit www.hcmarketplace.com.
Most Viewed
Most Emailed
- Some physicians not always honest with patients
- Keeping Readmission Rates Low with Treatment Guidelines
- Payment Cuts to Critical Access Hospitals 'Inevitable'
- Essential Health Benefits Bulletin Draws Fire
- CMS Reveals Central Line Infection Rates, Finally
- What If Your Car Cared About Your Health?
- Parkland Keeping Consultant's Analysis Under Wraps
- Engineering a High-Performance Emergency Department
- 2 Tactics for ICD-10 & VBP Clinical Documentation
- Getting to the Heart of Cardiology Alignment
