Author: SHP Staff

Upcoming Spring Webinars – Georgia Legislative Session Recap & Surprise Billing Legislation

Upcoming Spring Webinars – Georgia Legislative Session Recap & Surprise Billing Legislation

SHP is excited to announce two upcoming webinars this Spring. These timely webinars will delve into the most recent healthcare changes from the 2021 legislative session as well as how to understand the rules issued by the DOI for Surprise Billing. Join these free webinars with the links below. We will also post recordings and material in our webinar archive after the session.

Wednesday, April 14, 2021 at 12:00 noon: Georgia Legislative Session Recap

Please join SHP’s Legislative Affairs Team for a recap of key legislation from the 2021 session and to understand what bills will impact you in the coming year! A mini COVID update will be provided with the latest news from HHS and the American Rescue Plan. Use this link to join us at 12:00pm Eastern on Wed. April 14th!

Wednesday, May 5, 2021 at 12:00 noon: Georgia’s Surprise Billing Legislation

SHP will be joined by Michele Madison pf Morris, Manning & Martin to discuss the enactment of Georgia HB 888 for Surprise Billing by healthcare providers. HB 888 took effect on 1/1/2021 utilizing a set of operational rules and regulations developed by the Department of Insurance (DOI). Join us at this link to learn about the impact that this will have on your operations on Wed. May 5th!

3 Questions About Your Supply Chain

  1. What percentage of your total operating budget does Supply Chain represent?

Most healthcare executives understand that Supply Chain makes up the second largest part of any hospital budget next to labor, but understanding the true amount really depends on what you consider part of your Supply Chain.

Progressive healthcare organizations are now recognizing Supply Chain as any non-labor costs to the organization. It is no longer just medical and non-medical supplies. The definition should include all capital, leases, services, plant maintenance, food, pharmacy, printing, marketing and anything other than labor that generates an invoice. If your organization has adopted this understanding of the broader scope of Supply Chain, your understanding of the true percentage of your total operating budget has changed too.


  1. Is Supply Chain cost reduction part of your Strategic Plan?

Healthcare organizations focus a lot of fiscal attention on revenue management and controlling labor costs and tie them into objectives and initiatives in their Strategic Plans. Many include some type of cost reduction objectives, but most do not include tactics or methodology that truly track and attempt to control Supply Chain costs. Fewer still have any processes in place that accurately measure cost savings initiatives against additional new product costs that have been added to the organization.

A true Supply Chain cost reduction strategy must include the following components:

–       Analytical review at the department level of actual supply costs compared to budget is key to this strategy. Understanding and utilizing the report tools available in the Materials Management Information System (MMIS) will provide a level of supply cost detail only summarized in the GL reports. Department heads and administrators alike need to learn these tools and use them.

–       Target realistic cost reduction goals by department and track them month by month. If supply costs are up for a given month, patient volume and gross revenue should be the justification. If not, there needs to be a corrective action plan based on an in-depth analysis to bring supply costs back in line.

–       Develop dedicated Value Analysis Teams. While many know what Value Analysis Teams are, very few organizations make the long term commitment to them. Administration must be committed and directly involved if they expect success and sustainability.

–       While it is important to track cost reduction initiatives and successes, it is equally important to track all new or added costs for administratively approved requests. This is the only way to accurately measure the full picture. New technology and requests are inevitable, but as these unbudgeted costs are approved, you should be challenging the source of the offsetting cost reductions. Otherwise, your explanations for supply budget variances will be anecdotal, non productive, and a detriment to your financial goals.

  1. Is      your Supply Chain model centralized or decentralized?

If you are not sure what the difference is, then you probably have a decentralized supply chain model. The traditional, decentralized model is one where Materials Management is only responsible for the cost and management of supplies in their warehouse. This may or may not include inventory in Central Supply or Central Sterile. Most importantly, it does not account for all of the direct order (non-stock) purchases for the rest of the facility. This is ironic when you consider the amount of labor and effort that goes into managing a perpetual inventory in the typical storeroom system; yet represents only fraction of the total Supply Chain expenditures.

A centralized Supply Chain process is where the Materials Management department controls and is directly involved in:

–        all new item builds in your IT system – both for the item master and also the chargemaster as applicable

–       sources, negotiates and maintains pricing contracts (GPO or otherwise)

–       vendor controls and check-in process

–       manages a centralized service contract portfolio with expiration terms, leads/assists the negotiation process, and supports the financial budget forecasting process for service contracts (including new capital coming out of warranty)

–       Involved in the budgeting, sourcing and negotiations for the overall Capital process

–       Facilitation of the Value Analysis Team.  Specifically, researching and presenting all new item requests, sourcing alternatives, assisting in the reimbursement analysis and by tracking the actual cumulative costs of approved items.  During this process, Materials Management MM will conversely present products with cost reduction potential for clinical acceptance.

Doctors complain they will be paid less by health exchange plans

Article reposted from NBC News:

Written by:  Roni Caryn Rabin, Kaiser Health News

Many doctors are disturbed they will be paid less — often a lot less — to care for the millions of patients projected to buy coverage through the health law’s new Health Exchange marketplaces.

Some have complained to medical associations, including those in New York, California, Connecticut, Texas and Georgia, saying the discounted rates could lead to a two-tiered system in which fewer doctors participate, potentially making it harder for consumers to get the care they need.

“As it is, there is a shortage of primary care physicians in the country, and they don’t have enough time to see all the patients who are calling them,” said Peter Cunningham, a senior fellow at the nonpartisan Center for Studying Health System Change in Washington D.C.

If providers are paid less, “are [enrollees] going to have difficulty getting physicians to accept them as patients?”

Insurance officials acknowledge they have reduced rates in some plans, saying they are under enormous pressure to keep premiums affordable. They say physicians will make up for the lower pay by seeing more patients, since the plans tend to have smaller networks of doctors.

But many primary care doctors say they barely have time to take care of the patients they have now.

The conflict sheds light on the often murky world of insurance contracts in which physicians don’t always know which plans they’re listed in or how much they’re being paid to treat patients in a particular plan. As a result, some doctors are just learning about the lower pay rates in some plans sold in the online markets, or exchanges

“If you’re a physician and you’ve negotiated a rate from insurance, shouldn’t it be the same on or off the exchange?” said Matthew Katz, executive vice president of the Connecticut State Medical Society. “You’re providing the same service.”

Blues: No desire ‘to gouge’ docs A senior executive at Blue Cross Blue Shield Association said some of its 37 member organizations – each of which operate independently and offer a variety of plans – are offering lower rates to physicians in smaller exchange plan networks.

But, she said, plans know that a good network of providers is essential or customers “will go someplace else,” and they are enlisting sufficient numbers of doctors.

“We’re not motivated to gouge the doctor,” said Kim Holland, Blue Cross Blue Shield Association executive director for state affairs. “We depend on good relationships with quality physicians. … I can’t imagine any product we offer is going to have a physician rate that would discourage them from seeing a patient.”

But some physicians see things differently. Contracts between insurers and doctors vary with some allowing insurers to adjust rates unilaterally or to assign a doctor to multiple plans.

“I’ve participated with Oxford since 1985. They don’t send me a contract every year to sign. They don’t send me the rates. You don’t know the rates,” said Dr. Paul Orloff, a physician who is president of the New York County Medical Society. “It’s the only game in town so you sign. They have a right to unilaterally change the rates at any time during the contract.”

The benchmark for physician fees is the rate the federal government sets for services provided to older Americans through Medicare. In many markets, commercial plans may pay slightly above the Medicare rates, while doctors say that many of the new exchange plans are offering rates below that.

Physicians are uncomfortable discussing their rates because of antitrust laws, and insurers say the information is proprietary. But information cobbled together from interviews suggests that if the Medicare pays $90 for an office visit of a complex nature, and a commercial plan pays $100 or more, some exchange plans are offering $60 to $70. Doctors say the insurers have not always clearly spelled out the proposed rate reductions.

Some experts minimized the impact of lower pay rates on enrollees.

People “may experience wait times to get in, but that is not unique to people in exchange plans,” said Sara Rosenbaum, a professor of health law and policy at George Washington University,

Rosenbaum said she was not overly concerned about physicians’ compensation. “I don’t mean to suggest that physicians don’t deserve to do well,” she said. “But physicians are very well-compensated people, no matter what.”

Confusion about rates, provider lists Many doctors say they have not decided if they will participate in the new plans – in some cases, even when an insurer is including them in their provider list.

A survey by The Medical Society of the State of New York found that 40 percent of more than 400 physicians who had responded so far said they chose not to participate in a health insurer’s exchange plan, and one-third said they did not know whether they were participating or not.

“I have patients calling my office and saying … ‘Oh good, I see you’re in the network,’” said Patricia McLaughlin, an ophthalmologist in New York City. But, she added, “I’m not sure I am or am not at this point.”

Some insurers have contractual arrangements with physicians that allow them to automatically include doctors in a new plan, unless the physician requests to opt out in writing, according to Mike Scribner, CEO of Strategic Healthcare Partners, a health care consulting firm based in Savannah, Ga., that represents about 700 physicians and 30 managed care hospitals in the state.

Dr. Richard E. Thorp, an internist who is president of the California Medical Association and heads a physician-owned multi-specialty primary care group in Paradise, Calif., said one plan sold on that exchange “was going to pay us significantly less for doing that business. And we are already very busy.”

His practice delayed signing a contract, he said. But about three weeks ago, the group was informed the insurer was short on physicians and was therefore including doctors from other plans at their old rates.  So his practice was included at the higher rate.

Advocates say that consumers should be wary of information in plan directories and confirm participation with their doctors.

The California Medical Association is so concerned about errors that it has asked Covered California, the state’s insurance marketplace, to remove a search function that lets buyers plug in the names of physicians and get a list of all the plans that they participate in, said Lisa Folberg, vice president for medical and regulatory policy for the California Medical Association.

“There shouldn’t be any ambiguity about who’s in the network,” said Lynn Quincy, a senior analyst with Consumers Union, the policy division of Consumer Reports.

“These consumers are buying a product, one dimension of which is to provide a network–a very important dimension.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.


BCBSGA Healthcare Exchange Products

There is ongoing confusion over the physician panels that BCBSGA utilized for their healthcare exchange products.  In an effort to address this confusion, BCBSGA has just published updated directories for the new healthcare products that they will be marketing effective January 1, 2014:

This link includes directories for the “Pathway” and “Pathway X” product lines; “Pathway X” products will be sold on the Healthcare Exchange while “Pathway” products will be sold on the commercial marketplace.

BCBSGA confirmed to the Medical Association of Georgia (MAG) that these provider directories are completely accurate and they have removed all physicians who submitted prior opt out notifications to BCBSGA. Therefore, SHP encourages all our clients to view each directory in the above link to determine if your physicians are listed as participating providers.  If your physicians are listed and you previously submitted an opt-out notification to BCBSGA, please contact BCBSGA immediately to inquire about your continued listing in these directories. We would also greatly appreciate it if you could let us know as well.

In addition, the Medical Association of Georgia (MAG) recently met with BCBSGA to obtain clarification about BCBSGA’s new product lines and BCBSGA confirmed that the rate schedules for the Pathway and Pathway X product lines would match the rates from the Direct Access amendments that were disseminated to providers this past spring. If you are included in the Pathway/Pathway X directories, it is critical to understand your Pathway/Pathway X rates as these product lines are not just limited to the healthcare exchange but will be marketed to commercial beneficiaries as well.

Finally, it is anticipated that BCBSGA will be sending HMO plan rate amendments to providers within the next month.  We are significantly concerned about the combined impact from the introduction of the Exchange plans as well as reimbursement adjustments for your BCBSGA commercial product lines; particularly as the number of BCBSGA commercial beneficiaries will be growing significantly effective January 1, 2014 when the State Health Benefit Plan lives transition into the BCBSGA HMO product lines.

Health Exchange Webinar

Strategic Healthcare Partners (SHP) continues our series on Health Exchanges and impact on providers.  Please join us this Wed, 10/16 from 4pEST – 5pEST.  Contact Jason Crosby at or 912-544-0421 with any questions. 

Space is limited, please reserve your seat now at:

Title:  Health Exchange Webinar

Date:  Wednesday, October 16, 2013

Time:  4:00pm – 5:00pm EDT


After registering you will receive a confirmation email containing information about joining the Webinar.

CMS Implementing Updated 1500 Claim Form

CMS has recently announced that they will be implementing an updated CMS 1500 form for all paper claims filed to Medicare.  The revised CMS 1500 form (version 02/12) will have the following additional functionalities:

• Indicators for differentiating between ICD-9-CM and ICD-10-CM diagnosis codes.

• Expansion of the number of possible diagnosis codes to 12.

• Qualifiers to identify the following provider roles (on item 17)

  • Ordering
  • Referring
  • Supervising

Medicare has established the following tentative timeline to phase in the use of CMS 1500 form (version 02/12):

  •  January 6, 2014: Medicare begins receiving and processing paper claims submitted on  the revised CMS 1500 claim form (version 02/12).
  •  January 6 through March 31, 2014: Dual use period during which Medicare continues to receive and process paper claims submitted on the old CMS 1500 claim form (version 08/05).
  •  April 1, 2014: Medicare receives and processes paper claims submitted only on the revised CMS 1500 claim form (version 02/12).

In addition, CMS is currently updating the Medicare Claims Processing Manual with instructions about completing the revised forms.

Please see the full notice in the following MLN Connects Newsletter:

In addition, the new version of the CMS 1500 form can be viewed at the following link:

In preparation to begin using the revised forms, SHP encourages our clients to work with their EDI vendors/clearinghouses/billing software companies to ensure compliance with the new CMS 1500 forms.

Judge Refuses to Block SHBP Contract Stating that UHC Has Not Exhausted Appeals Process Through DCH

Yesterday, UHC appeared in court in an attempt to block DCH from awarding the SHBP contract to BCBSGA.  However, the judge in the case refused to block the contract; indicating that UHC still has appeals processes to pursue through the Department of Community Health (DCH).  The article below details the arguments made by the parties in the case (including BCBSGA, UHC and Kaiser) and also noted that DCH has significant latitude in how they select and award the vendor contract for the SHBP:

SHP will continue to monitor the developments as it is anticipated that UHC will continue its appeals processes through the Department of Community Health (DCH).

DCH Addresses SHBP Award Process

DCH had announced an intent to award the State Health Benefit Contract to BCBSGA

After DCH’s announcement, United Healthcare had indicated that a separate, non-inclusive bid process had occurred for the SHBP contract and that they had been excluded from bidding. UHC was planning on contesting the contract award to BCBSGA.  Late last night, DCH acknowledged that there had been two separate SHBP contracts out for bid:

The first contract was for a statewide SHBP vendor; this contract was open to all bidders, including United Healthcare.  According to DCH, this process to award the SHBP statewide contract was run according to state regulations and will continue along the normal path.  It therefore appears that following the appropriate 10-day window, there will be am announcement that DCH will be awarding the SHBP statewide contract to BCBSGA.

The second contract was for a regional SHBP vendor; this contract was not open to all bidders. Therefore, DCH announced its intention to revise the bidding process for the regional SHBP vendor and will be announcing additional timelines and processes for this contract. Also, it is important to note that DCH made no indication of what regions in the State they were planning to cover with this second regional vendor.

United Healthcare continues to protest the awarding of both contracts for the State Health Benefit Plan and wants the bidding process to be re-opened for both.

Additional details can be viewed in the article below:

SHP will keep tracking the SHBP contract process.

Deadline Approaching…DCH Requirements for Ordering, Prescribing, Referring Physicians Takes Effect on 7.1.2013!!!

As a reminder, effective 7.1.2013, all physicians or other practitioners who prescribe or order services for Medicaid recipients or who refer Medicaid recipients will have to be enrolled as a Medicaid provider.  Services that are rendered based on a referral, order or prescription will be reimbursed only if the ordering, referring or prescribing physician/practitioner is enrolled in the Georgia Medicaid program.  If you are already enrolled as a Medicaid provider, you do not need to also enroll as a Medicaid OPR provider. However, it will be critical to ensure that when you perform services for Medicaid patients that were ordered, prescribed or referred by another practitioner for dates of service of 7.1.2013, that the other practitioner is enrolled as an active or OPR Medicaid practitioner.

DCH has also published an FAQ on the new requirements for Ordering, Referring and Prescribing providers which can be accessed at the following link:

SHP wants to highlight the following FAQs that were included in DCH’s posting:

1.  Referrals, Orders & Prescriptions from Out-of-State Providers:

 Federal law requires all OPR physicians or other professionals rendering services under the State Plan to be enrolled as providers. The provider that ordered, prescribed, or referred the services must be enrolled in the Medicaid program in which the beneficiary is eligible, in this case Georgia Medicaid. The NPI of the out-of-state OPR provider must be included on the claim for payment to the provider rendering the services ordered, prescribed, or referred. Therefore, a provider outside Georgia who orders, prescribes, or refers services must be enrolled in the Georgia Medicaid program for Georgia Medicaid to pay the claim of the participating provider who actually renders the service. This includes physicians or other professionals employed at hospitals or other health care facilities.


2.  CMO Claims (Amerigroup, Peach State Health Plan & WellCare):

This new OPR requirement does not apply to orders, prescriptions or referrals for individuals enrolled in a Medicaid CMO. It is applicable only to the Georgia Fee for Service (FFS) Medicaid Program.
3.  How will you be able to tell if an OPR provider is enrolled in Georgia Medicaid:

The Georgia Medicaid Management Information System (GAMMIS) Web Portal at: will have a search capability so individuals and entities will be able determine if an OPR provider is enrolled in Georgia Medicaid.