Close Close
Popular Financial Topics Discover relevant content from across the suite of ALM legal publications From the Industry More content from ThinkAdvisor and select sponsors Investment Advisor Issue Gallery Read digital editions of Investment Advisor Magazine Tax Facts Get clear, current, and reliable answers to pressing tax questions
Luminaries Awards

Life Health > Health Insurance > Life Insurance Strategies

Plans And Providers Clash Over Fee Data

Your article was successfully shared with the contacts you provided.

Consumers may shy away from the new “consumer-driven” health plans because of a lack of meaningful information about the cost of medical care.

A team of U.S. Government Accountability Office researchers led by John Dicken, a GAO director, has published that conclusion in a review of the CDHP market.

The GAO researchers looked at high-deductible health insurance plans that offer insureds access to health reimbursement arrangements or health savings accounts.

Although more than 5 million U.S. residents have HRAs or HSAs, many of those health account holders have a difficult time using account assets, the researchers write.

Only 3 of 5 multistate CDHP health insurers studied offered patients access to pharmacy-specific prescription drug prices.

None of the health insurers offered patients access to “actual negotiated” physician-specific or hospital-specific payment rates.

Negotiated rates matter because insurers rarely pay providers’ “list prices.” Instead, insurers and providers usually use complicated contracts to come up with discounted prices.

Companies such as the Metavante unit of Marshall & Ilsley Corp., Milwaukee, or Evolution Benefits Inc., Avon, Conn., have used debit cards as the basis for developing automated claim handling systems.

In many cases, health insurers can use the automated systems to apply any contractual discounts. A card holder can pay a correctly “repriced” claim while still in the provider’s office, according to the card companies.

In the real world, many health account holders are just starting to get health account debit cards, the GAO researchers write.

In a typical case, a provider may submit a claim to the insurer after seeing the patient. The insurer may take as long as 6 weeks to tell the patient what the repriced bill will be, the researchers write.

“During this time period, the patient, who may incur other health care expenses, is left uncertain of the amount that will be withdrawn from the HSA, and therefore cannot determine the remaining balance,” the researchers observe.

The CDHP insurers told GAO researchers that “physician-specific cost and quality data would be difficult to collect and report until the physician community agreed that the value of providing these kinds of information to customers outweighed any potentially negative personal ramifications,” the researchers write.

Meanwhile, the American Medical Association, Chicago, has published a draft report suggesting that insurers may be at least partly to blame for the lack of price data.

One key problem is that physicians have no way to know how insurers will reprice claims, the authors of the AMA draft note.

Because of uncertainty about insurance payments, “it is very difficult, if not impossible, for the physician to provide the patient with information about the patient’s out-of-pocket cost for a service or procedure,” the authors write.

AMA members also worry that “negotiated price” databases may leave out information about contract terms that reduce the amounts insurers actually pay physicians.

A copy of the GAO report is on the Web at Document Link


© 2024 ALM Global, LLC, All Rights Reserved. Request academic re-use from All other uses, submit a request to [email protected]. For more information visit Asset & Logo Licensing.