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The Nightmare of Health Insurance Bureaucracy

Joe Cantlupe, for HealthLeaders Media, March 10, 2010

After 18 months of working, "We are still waiting for the final OK," Arnold says with frustration.

In the meeting with the AMA, Arnold told of "substantial problems with payer legacy IT systems—such as how to code management fee and bonus payments—especially for large, self-funded employers who have existing fee-for-service contracts based on medical clams and a fixed administrative payment to plan."

Because of the need for flexibility in IT and other aspects of making the pilot program work, negotiations also have been flexible—on the local level, Arnold says. However, when the project "has gone up to the executive suites, it's been stalled," he says.

But Arnold has tried to go behind the curtain and see the problems through the payer's vantage point.

"The biggest hangup for the payer has been how to administer and how to pay for it," he says. "How do you bill self-funded employers for a PCP (primary care physician) management fee when their contract is based on claims paid?"

A lot of these new payment methods are really difficult to administer, Arnold says, "It's an academic exercise without significant payer involvement and support."

"It has become an administrative nightmare," he says. The payers, he told the AMA, "seem so risk adverse."

Insurers would have likely been the proverbial fly on the wall during Arnold's talk in DC last week. Arnold spoke from experience and frustrations. Health insurance companies can learn from Arnold and the Connecticut program and understand that they will have to remove these kinds of barriers if the two sides are to work together.


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Joe Cantlupe is a senior editor with HealthLeaders Media Online.
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