The Nightmare of Health Insurance Bureaucracy
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.
Note: You can sign up to receive Health Plan Insider, a free weekly e-newsletter designed to bring breaking news and analysis of important developments at health plans and other managed care organizations to your inbox.
Joe Cantlupe is a senior editor with HealthLeaders Media Online.
- As Medicare Advantage Cuts Loom, Disagreement Over Program's Stability
- Doctors Feel Pressure to Accept Risk-based Reimbursement
- Surgical Checklists Unused in 10% of Hospitals, CMS Data Shows
- Centralizing the Revenue Cycle Protects the Bottom Line
- A Fresh Look at End-of-Life Care
- 3 in 4 Patients Want E-mail Consultations
- Heart Attack Patient Costs Skyrocket Beyond 30 Days
- CA Fines 8 Hospitals for Medical Errors
- ACGME Chief Sees 'Huge' Risk of Error in Proposed Assistant Physician Licensure
- 3 Insider Tips on Cutting Costs without Strangling Growth