If you’re not sure what your managed care payers want from you, maybe you need to tell them. Many physicians are (understandably) complacent about taking an active role in defining in their payer relationships. Not surprisingly, managed care payers have had very little incentive or ability to negotiate special arrangements with a diverse and disintegrated physician practice marketplace. However, as the marketplace consolidates, larger independent physician practices may have an opportunity to begin to define in their payer relationships.

Many physicians believe that insurance companies have exclusive access to the data necessary to define the specific cost controls and quality measures they will demand from the physician marketplace. In fact, while payers have historically had access to more utilization and quality data than the physician practices, with the implementation of electronic medical records and sophisticated IT systems, larger practices now have access to key data with which to define their quality, cost and utilization data. Very often when I talk to physicians about negotiating their managed care arrangements, they say that they don’t know what their payers are looking for. Consider, however, that this may be because the payers themselves don’t know what they are looking for.
 


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Hospital-owned practices may take an unexpected hit in revenue under a new Medicare rule that bundles certain physician service fees into hospital payments. The so-called “payment window” rule (sometimes referred to as 3-day/1-day window rule) requires a hospital (or an entity that is wholly owned or wholly operated by the hospital) to include on the claim

On November 24, 2009, the U.S. House of Representatives passed the Medicare Physician Payment Reform Act" (H.R. 3961) which would repeal the scheduled 21% fee reduction scheduled for January 2010.  The legislation would also permanently replace the existing Sustainable Growth Rate (SGR) formula with a new formula that, according to the House summary:

  • Removes items such as drugs and

Despite efforts by Senator Harry Reid to pass legislation which would have effectively frozen Medicare payment rates for physicians, it looks like Congress will once again look to freeze physician payment rates with a one-year patch. According to an article published by the Wall Street Journal, Senator Reid’s proposed bill would have permanently prevented