All Entries Tagged With: "payers"

CMW News: Insured cancer patients struggle to afford treatment

Patients with cancer undergo many expensive treatments and tests and often find themselves bankrupt even if they have insurance, according to a new report.

The report, released by the Kaiser Family Foundation and the American Cancer Society followed 20 typical cancer patients. Of those patients, nine had insurance through an employer, one paid for employer coverage through COBRA, seven had individual insurance, two received coverage through a state high-risk insurance pool, and one became uninsured. [more]

CMW News: California bans “balance billing”

The California Supreme Court recently ruled that physicians can no longer bill patients for emergency room treatments that physicians feel HMOs do not adequately pay.

HMOs and patient advocates celebrate the decision as a way to stop physicians and hospitals from overcharging for emergency services. Physicians say the court has taken away their only leverage against HMOs to receive fair payments, and this ruling may put emergency departments in economic jeopardy.

Regulations require HMOs to pay physicians and hospitals reasonable amounts, but do not specify what constitutes reasonable.

Sources: HealthLeaders Media, Los Angeles Times

Improve patient advocacy by creating a managed care partnership

Managed care companies are viewed as the Goliath to a case management program’s David. Although they may be perceived by some as the angry giant battling the defenseless healthcare facility, some organizations have found there’s a friendly way to allay an intimidating beast.

One hospital says, however, that creating a partnership with a managed care company doesn’t have to be a battle.

“ When you create a trusting partnership with managed care companies, greater opportunities for patient care present themselves,” explains Laura Ostrowsky, RN, MPA, CCM, director of case management at Memorial Sloan-Kettering.

In 2003, Ostrowsky set out to develop a patient advocacy program under her facility’s case management umbrella with the help of Robin Campbell, RN, MPA, insurance liaison manager at Memorial Sloan-Kettering.

Campbell and Ostrowsky knew the program would require a solid educational component for physicians and patients. To ensure a solid case for patient treatment, Memorial Sloan-Kettering’s case managers are diligent about:

• Collecting data on progressive treatments Memorial Sloan-Kettering performs that other facilities might not
• Analyzing the data to identify trends of success, which are later used to build a case for payers
• Determining how to present the data to get the best financial return from payers

We highlight this story, in detail, in our January issue of Case Management Monthly, but what are you doing at your facility to improve relationships with your managed care companies. What are some struggles you face?