News You Can Use

What to Consider With Fee-For-Value Health Plans

Health plans, Centers for Medicare and Medicaid Services (CMS), and national news are touting the ongoing move from straight fee-for-service healthcare into fee-for-value healthcare. Upon initial glance, fee-for-value models absolutely provide new revenue streams for healthcare providers. However, when considering a fee-for-value partnership with a health plan; it is critical for providers to fully consider their dependency on the health plan for accurate, detailed reporting and reconciliation. Whether it is recognizing all submitted diagnosis codes for accurate risk adjustment or financial allocation of the patient’s care; providers have very little ammunition to fight any performance indicators rendered by a health plan.

Even providers currently in fee-for-value arrangements and receiving regular incentives or distributions from health plans cannot accurately assess whether they are maximizing their opportunities without relying on the health plan. Particularly for Medicare Advantage, providers are the key partners that allow the health plan to maximize revenue through risk adjustment and STARS performance and providers should ensure that they are accurately reaping the rewards that the health plan is receiving.

This lack of transparency becomes even more critical as providers consider the move to downside risk.  Accepting financial responsibility for a health plan’s determinations can become detrimental without any method of independently verifying those results.  These are important considerations for all providers to make when partnering with a health plan in a fee-for-value model.

Click here to learn more about our contracting services and how we can help you evaluate your options.

FHIR Finally Breathing Interoperability

Business connection concept.

With 82% of hospitals and 64% of Merit-Based Incentive Payment System (MIPS) Eligible Clinicians using EHR technology supported by Fast Healthcare Interoperability Resources (FHIR®), it might be time for patients, providers, and health systems to finally expect complete and centralized personal health records. FHIR is a pivotal turn for Health Level Seven (HL7®) to essentially turn your EHR into an application platform allowing immediate access to secure data sources, like your iphone, android, or smart TV centralizes banking information, mobile health information, and an endless supply of capabilities competing for screen time. FHIR provides a secure transformation of health information across disparate data sources, this ultimately can lead to reduced administrative quality reporting burdens, more timely transfers of personal health records (PHRs) across EHRs, even reliable biometric data monitoring within PHRs, and much more.

This swift technological advancement breaks down data exchange barriers, largely in pursuit of population health capabilities encouraged by HL7s Argonaut Project which health information technology juggernauts such as Epic, Cerner, AthenaHealth, and provider organizations like Intermountain Health and Mayo Clinic. To a layperson, these organizations are using FHIR to essentially share meaningful clinical data on secure internet-based platforms (Think of an https:// address) called resources, that allow other entities to build off of this flexible set of data, including imaging results, lab tests, longitudinal care plans, etc.

This industry sweeping capability raises the temperature for data blocking, recently referred to as ‘patient profiteering’ by CMS administrator Seema Verma who points out the financial incentives for health systems, vendors, or payors that purposefully contort patient data to maintain market share. The Office of the National Coordinator for Health Information Technology (ONC) will soon propose further teeth in the 21st Century Cures Law by defining data blocking instances to penalize with fines and decertification.  This proposal is expected in December, which will then lead to a period of public comment. Congress has specifically focused on defining and regulating application programming interface (API) capabilities that halt data-sharing by intentionally forming proprietary data agreements to gain competitive market advancement.

So, what’s the point? Interoperability may not be a day-to-day must-have for most providers and administrators in 2019, however it could finally connect disparate sources of health information in a clinically and practically relevant fashion in the very near future.  Real-world clinical practice scenarios will drastically transform if FHIR continues to gain traction as the world’s brightest technology innovators compete for providing the most clinically relevant information sharing, within your existent EHR platforms.

Can Existing Technology Really Save Rural Hospitals?


Between 2013 and 2017, nearly twice as many rural hospitals (64) closed their doors than the previous 5-year period; predominately located in the south, according to a recent publication by the U.S. Government Accountability Office.  Through shrinking commercial reimbursement rates, increasing dual-eligible Medicaid-Medicare beneficiary populations, competition with alternative care settings (Urgent care, Minute Clinics, etc.), transitioning payment models and the usual complex nature of rural healthcare finances, rural hospitals find few opportunities for new revenue sources.  Considering the often-devastating impact of losing our rural caretakers within our communities, let’s take a quick pulse of the technology 2018 brought, that could potentially boost 2019’s income statement, if implemented wisely.

  1. Telehealth: Telehealth services bring obvious and immediate communication convenience to patients and staff alike. Instituting e-health billable services and billable chronic care management or transitional care programs, can be a bit of a challenge at first; though they routinely lead to recurrent revenue strategies for America’s rural hospitals. On top of that, virtual visits and remote monitoring bring a complicated logistical, scheduling, and reimbursement opportunity as well as an increased expectation of availability. The lesser understood benefit here, however, is the ability to institute upfront payment for such convenient services. As patient liability continues to rise to roughly 20% of outstanding allowables, the uniquely “brand-spanking new” nature of telehealth services allows an opportunity to collect patient portions immediately. Consumer-minded patients seek convenience; thusly, the question to ‘Press 1 to pay now’ is much more palatable while waiting for a convenient e-visit. Instituting recurrent revenue streams by introducing telehealth services throughout the daily workflow, can turn “Found Time” to “Billable Time.”
  2. Routine Follow-Up Care: Define it as telehealth, EHR utilization, population health or simply patient outreach – Every health system or physician practice can re-evaluate how efficiently we utilize technology to contact our patients. Providing routinely effective follow-up care is the starting point for not only the best possible clinical outcomes, but also maintaining patient loyalty, reducing readmissions and unnecessary ED utilization, and providing a top-notch patient experience. While hospitals handle telephone encounters and routine follow-up care differently, most often utilizing technological strategies instituted several years ago, it is always worth re-evaluating your outreach and use of business intelligence to monitor your success rates. This does not imply purchasing anything new, but often implies restructuring familiar and deeply ingrained workflows and internal skill sets.
  3. Partnerships with Data: Whether you’re providing teleradiology reading services, sharing in population health initiatives, Health Information Exchanges, or partnering with cloud-based HIT providers, the enormous influx and importance of data-driven decision-making continues to rise. Data accuracy, integrity, and reliability all continue to grow in variance from the high-end partnerships with continuously reputable results down to incomplete and incoherent data-sourced partnerships. When considered a priority, rural hospitals with keen eyes for technological solutions, often can find applicable alternatives via partnerships, without major disruptions in workflow or collections. Routinely reviewing current contracted claim payments, understanding the timing of patient liability payments, and reviewing the continuity of care services are the mere tip of the analytical iceberg rural hospitals must be successful in doing on a routine bases. Navigating the relative impact of which data-driven partnerships to pursue will continue to keep our rural hospitals afloat and thriving as our industry continues evolving.

To quote Charles Darwin….”It is not the strongest of the species that survives, nor the most intelligent, but the one most responsive to change.”

Click here to learn about our services and how we can help rural hospitals identify strategic opportunities.

Top 10 Healthcare Headlines from 2018

From mergers and vertical integrations to changes in quality reporting and technology, Healthcare in America continues to evolve with an eye on access, quality, and efficiency. Here is a look back at some of the major headlines of 2018.


Amazon made another bold move into healthcare that went relatively unnoticed
Published by Healthcare Finance News

“Amazon expanded into the Medicaid market by announcing that it will offer beneficiaries a Prime membership of $5.99 a month, a discount of 54 percent. And while that revelation last week may not have raised quite as many eyebrows as the company’s blockbuster partnership with Berkshire Hathaway and JPMorgan Chase it holds the potential to have a major impact sooner.”

Click here to see the full article.


CMS Administrator Seema Verma calls for an end to physician fax machines by 2020
Published by Healthcare Finance News

“The Office of the National Coordinator for Health Information Technology and the Centers for Medicare and Medicaid Services are working together to realize a shared vision for a health ecosystem that sees the free flow of information between patient, provider and payer.”

Click here to view the full article.


Electronic Health Records Associated With Lower Hospital Mortality After Systems Have Time To Mature
Published by Health Affairs

“These findings suggest that national investment in hospital EHRs should yield improvements in mortality rates, but achieving them will take time.”

Click here to view the full article.


How Amazon, JPM, Berkshire could disrupt healthcare (or not)
Published by Healthcare Dive

“Merger mania in the healthcare space is indicative of industry wide uncertainty. The various stakeholders will try anything to better the system. Whether it’s CVS and Aetna, Amazon, Berkshire Hathaway and J.P. Morgan Chase, Ascension and Providence St. Joseph, they will use their scale, business savvy and technology, to drive costs out of the system — something CMS has struggled to do on its own.”

Click here to view the full article.


List: Healthgrades reveals America’s Best Hospitals for 2018
Published by Healthcare Finance News

“The Healthgrades analysis showed that those hospitals recognized as America’s Best did better than their peers in treating a core group of conditions that cause more than 80 percent of mortalities in areas evaluated, including heart attack, heart failure, pneumonia, respiratory failure, sepsis and stroke.”

Click here to view the full article.


More employers go direct to providers, sidestepping payers
Published by Healthcare Dive

“Some large employers are even sidestepping health insurers and contracting directly with providers. Another recent Willis Towers Watson survey found that only 6% of employers contract directly with providers now, but 22% are considering it for 2019.”

Click here to view the full article.


New Medicare Advantage rules hold big potential for pop health
Published by Healthcare Dive

“CMS issued a final rule in May giving MA plans more flexibility in determining the types of supplemental benefits they can offer chronically ill enrollees, including nonmedical benefits. The new policy, part of a broad 2019 Medicare payment rule, means plans like UnitedHealthcare and Humana aren’t harnessed to a set palette of supplemental benefits for members with chronic conditions, but can tailor them to the specific needs of individuals.”

Click here to view the full article.


Optum a step ahead in vertical integration frenzy
Published by Healthcare Dive

“UnitedHealth formed Optum by combining existing pharmacy and care delivery services within the company in 2011. Michael Weissel, Group EVP at Optum, told Healthcare Dive the company began by focusing on three core trends in the industry: data analytics, value-based care and consumerism.”

Click here to view the full article.


Rural And Nonrural Primary Care Physician Practices Increasingly Rely On Nurse Practitioners
Published by Health Affairs

“Overall, primary care practices are embracing interdisciplinary provider configurations, and including NPs as providers can strengthen health care delivery.”

Click here to view the full article.


See the list: CMS releases 2018 health plan star ratings
Published by Healthcare Finance News

“Star ratings measure the plan’s quality and performance in five categories: staying healthy screening tests, managing chronic conditions, member ratings of the health plan, member complaints and Medicare problems, and the handling of customer appeals.”

Click here to view the full article.



Medicare Advantage: In-Network vs. Out-of-Network

Medicare Advantage plans continue their unabated growth; in 2019, plan options across the United States have grown by 20% from 3,100 plans in 2018 to 3,700 plans in 2019.  By 2025, it is expected that Medicare Advantage market saturation will reach 50% of the Medicare-eligible population.

With unprecedented growth in these plans also comes increasing administrative challenges and roadblocks.  These range from never-ending record requests to non-Medicare claims payment methodology to lack of operational oversight on these issues.

As stewards of their communities; most healthcare facilities automatically participate in the health plans being sold in their markets.  In light of the increasingly challenging administrative burdens, it’s critical for healthcare facilities to seriously consider “Why Should I Contract for Medicare Advantage?”  In making a determination for in vs out of network participation; some of the key points worth considering are:

  • Type of Medicare Advantage Products in Your Market: what is the product saturation in your market?
    • PPO: In & Out of Network Benefits
    • HMO: No Out of Network Benefits
    • PFFS: No Network Offered; Benefit Level Identical at Any Service Location
  • Plan Design: can enrollees see you out of network with no negative financial impact?
  • Network Reimbursement:
    • Out-of-network services reimburse at Medicare rates using underlying Medicare methodology
    • In-network services reimburse at contracted rate using methodology developed by the health plan; some key differences noted in plan design:
      • Extensive recoupments
      • Non-Medicare methodology:
        • What are covered services?
        • Length of stay limitations
        • Sub-Medicare rate methodology
        • No alignment with CMS rate methodology; i.e. paying home health under per diem reimbursement methodology
  • Record Requests: Under CMS’s methodology for paying Medicare Advantage plans, health plans are laser focused on risk adjustment leading to a never-ending stream of onerous record requests. In an out-of-network position; there is no requirement to comply with these record requests.

It’s critical for managed care departments to weigh the benefits of being in-network with a Medicare Advantage plan and if that benefit outweighs the administrative burden.

Learn more about our managed care contracting services and how we can help.

Attracting Patients via Narrow Networks


Narrow networks have surged in attempts for health plans and employers to tame rising healthcare costs. In many ways, patients negatively associate the phrase, “out-of-network” with arbitrary limitations of their choice. Frustrating, we’ve all felt it. How then can provider networks bolster their network and promote increased accessibility, care continuity, and ultimately the best quality of care to their patients?

Narrow network strategies, form a business perspective, often begin and end at the negotiation table. However, providers practicing within intelligent networks can pounce on the opportunity to better understand their patient population and tailor services to meet their patient’s needs, while sustaining solvency in turbulent times. A common example of this includes patient scheduling via referrals.  Many Clinically Integration Networks (CINs) include a variety of independent practices and health systems that do not have centralized resources.  As a result, patients and the front desk staff understand the inefficiencies within most referral/scheduling practices.

Though your relationship across practices and specialists likely exists on paper, leveraging this relationship so two disparate practices can align themselves in easing the referral scheduling proves difficult. Especially if you’d also like to inform the patient of this assistance. Patients always find out when two EHR’s don’t talk to each other, can your network find the time to market the benefit of a finely established relationship that eliminates duplicate imaging, lab testing, and visits?

These basic questions are rarely resolved by basic answers.  Even when they do, many healthcare leaders often inflate the successfulness of their endeavors that may or may not impact the patient experience. So what can we do?

  1. Constant Contact. Ideally, you have a consistent and effective process in place to contact your patients. In an effective narrow network, your patients should be informed that you know who they are and what services you can offer them. Far too often patients are caught in a misaligned lack of understanding between their doctor, their insurance company, their pharmacy, and even hospital facility.  Welcoming your attributed patients with prioritized information sharing will increase your ‘stick rate’ (Patient Loyalty). If you have a process, ensure you are using business intelligence to learn how successful it really is. If you don’t have a process as a network, make this an easy win and develop an outreach strategy.
  2. Expand your traditional strengths. Take time to ensure primary and follow-up care is available within your network and even consider focus groups to detect errors. Detect internally suggested avenues for improvement in patient scheduling, referring, and transferring of records from your front desk staff. They know their work best, and they have the keenest insight on your patient’s difficulties.
  3. Create and foster a practice transformation workgroup. Governance structures often spawn out of necessity, sometimes even legal necessity. Despite the obligatory yawn imposed by the phrase “workgroup,” make patient navigation your necessity. Assign leaders from within the network to develop clinical pathway initiatives that simply make more sense. This creates internal ownership and evolves into accountability and a well-understood pathway for other ideas to come to fruition.
  4. Go Get Easy Wins. Most CINs focus on ambitious contracting goals that undoubtedly take time. While these negotiations develop, aim for opportunities to satisfy membership quickly with patient-facing victories. Furnish and polish a few concepts that your membership is already considering and bring resources for those providers to appreciate. Creating just a few clinical practice adjustments will become contagious and open the possibility to create real local change.

Interested in forming or joining a CIN? We can help. Click here to learn more.

Continuity of Care QPP Measures

Introducing continuity of care measures to the Quality Payment Program (QPP) may be the best route to lower healthcare costs and reduce hospitalizations according to a study recently published in the Annals of Family Medicine. Provider-level measures that support value-based payments by measuring true continuity of care have been lacking thus far in QPP. This led Dr. Andrew Bazemore to develop, and test 4 provider-level, claims-based continuity measures on over 1.4 million Medicare beneficiaries.  The results showed providers with the highest level of continuity were 14.1% lower in cost than those in the lowest quintile. In addition to the cost savings, the odds of merely being hospitalized decreases 16.1% for providers with a high continuity of care score.

Researchers utilized four established measures, the Usual Provider Continuity (UPC) Index, Bice-Boxerman Continuity of Care, Modified Modified Continuity Index (MMCI), and the Herfindahl Index (HI) to then create an average across provider-level patient panels. The strong correlation between these continuity of care measurements and both clinical and fiscal outcomes, builds a strong case for supporting further focus on care continuity with providers and clinical teams. This may not be all that surprising to primary care providers, as a stronger patient relationship is often given credit for better care. However, this is a big win in terms of bridging the gap between a world of healthcare dominated by data and the real world of complex dynamics between patients, providers, and individual life circumstances.

The applicability and ease-of-reporting for these four measures is astounding in comparison to the barrage of primary-care centric measures currently in QPP. Researchers noted, “Primary care has the largest number of QPP measures but most of these are intermediate, disease-focused, and process measures, which risk driving primary care focus away from its core functions and real value.”

As value-based payments continue to snowball into effect, support for reasonable, applicable measures that bring minimal reporting burden is encouraged. To learn more, please see the Meaningful Measures Initiative here.

Common CIN Pitfalls to Avoid

Mistaking Inaction for Action

Hesitant leaders can easily raise the red flag at any one of the many unclear pathways to success, that Clinically Integrated Network (CIN) conversationalists claim when discussing the ability to cultivate true innovation capable of both increasing care quality and reducing costs while simultaneously benefiting the bottom line for those putting in the work. The bar for successfully achieving the triple aim while operating a physician practice with fiscal responsibility may be high, however delaying clinical integration is allowing employment models to infiltrate markets with far less consideration for local autonomy and independence. Clinically Integrating locally, or regionally, significantly bolsters network position and market knowledge / IQ, promoting effective partnerships with the right payers and employers to build a portfolio of value-based contrasts that make sense to you. Delaying CIN formation decreases the likelihood of fostering a sophisticated arrangement of value-based contracts that can otherwise quickly introduce a barrage of conflicting quality measures and reporting nuances amongst your payers, wasting both time and money.

Innovators and Early Adopters Leaving Laggards Behind

In Diffusion of Innovations, Everett Rogers categorizes adopters of any market changes as a bell curve equally distributing innovators (2.5%) and early adopters (13.5%) who blaze new trails, early and late majority (34% each) who hesitantly adopt new marketplace realities, and finally laggards (16%) who represent true traditionalists in times of change. In healthcare, physicians and administrators alike can promptly identify themselves and their peers as representatives of one of those categories when it comes to clinically integrating financial incentives, intertwined with quality performance improvement. It is natural for physician champions to sway the opinions of the early and late majority, but completely neglecting the nay-sayers often sprouts problems down the line. The traditionalists have strong opinions for a reason, and their reasoning often can prevent the innovators from blindly leading the blind into complicated contracts structured with little chance of success. Discussing the depths of the included performance or outcomes measures, shared savings contingencies, and governance arrangements with those in opposition can cultivate a more thorough decision-making process and ultimately build better sense of trust within the organization down the road.

Expecting Early Results

Anticipating engagement from physician members, contracting partners, or local employer groups within a few years of clinically integrating, is an ambitious goal in it of itself. Though everyone knows change takes time, and change takes an even slower pace in healthcare, CINs often target unrealistic goals that often underestimate the lift required for many disparate initiatives. In the early days, each individual step of the clinical integration journey, as mundane as it may be, deserves celebration. Whether it’s merely defining governance responsibilities, stipulating the flow of funds, or implementing a data registry, each individual milestone is a short step towards a distant goal of contracting options with tangible financial benefit. Many CINs erroneously over-predict the number of contracts they will offer their members within a short period of time, causing frustration when physician members come to understand the slowly evolving nature of managed care contracting in 2018.

External Focus Instead of Inward Insight

The main objective of CIN members may, and should, be contracting activity, fair enough. However, it is easy for CINs to spend an excessive amount of meeting minutes, phone calls, and administrative effort in seeking external recognitions of palatable contracting offers when those offers would be more plentiful if the CIN built their internal brand first. CIN governance boards should be cognizant of the percentage time spent seeking outward recognition vs. bolstering internal capabilities. For example, payers and local employers, like everyone else in 2018, demand data. A successfully established population health product offering from a CIN requires internal focus to connect disparate data sources, develop and successfully implement interventions, determine and dissipate workflow adjustments or care redesign pathways to their broader membership, along with a laundry list of other tasks. CINs churning measurable population health initiatives onto their resume build stronger portfolios for negotiations than CINs waiting for payers to call back with their predetermined list of quality-based contract offerings.

Click here to learn about SHP’s CIN services.

2019 CMS Quality Payment Program (QPP) Changes

In 2019 the Centers for Medicare and Medicaid (CMS) are making changes to the Quality Payment Program (QPP). Below are the most impactful changes we think you need to know about. For additional information, click one of the links at the bottom of this post.

Performance thresholds increase substantially

  • Performance threshold to receive a positive adjustment has increased from:
    • 3 points in 2017, to 15 points in 2018, and now 30 points in 2019.
  • CMS anticipates continuing to increase this threshold by 15 points yearly.
  • Exceptional Performance Threshold increases to 75 Composite Points.

Projected Median of Composite MIPS Scores to drop by 12% according to CMS

MIPS Eligibility Expanded

  • CMS estimates 180,000 more eligible clinicians.
  • Physical Therapists, Occupational Therapists, speech pathologists, audiologists, midwifes, clinical psychologists, nutritionists, and dieticians all newly eligible.
  • Note that Clinical Social Workers were included on the 2019 Proposed Rule, but ultimately excluded.
  • Opt In options for low-volume clinicians. Low-volume clinicians are defined as meeting one of the following conditions:
    • >200 Part B patients per year
    • >$90k Part B billed charges
    • >200 services (newly introduced in 2019)

MIPS financial impact continues to become more relevant

  • Projected maximum incentive to increase from:
    • 88% increase in 2017 to an estimated 1.9% in 2018 to 4.7% in 2019.
    • Projected maximum incentive increases
  • Penalty Impact for low performance increases from +/- 5% in 2018 to +/-7% in 2019, CMS projects the total penalty/bonus money to hit roughly $390 million.
  • Projected maximum incentive increases as more clinicians receive substantial penalties. This bonus money available will become continuously more noticeable.

Hospital-based clinician flexibility

  • Facility-based reporting will be utilized for MIPS Quality and Cost categories by scoring on relative performance in the hospital value-based payment programs (VBP). Percentile-based performance from VBP will be proxied as a MIPS Quality performance for those providers.
  • Eligibility is targeted to be viewable on the QPP portal Q1 2019, CMS will also automatically determine whether quality reporting OR VBP reporting will give these providers a higher score.

Other Payer Advanced APMs offered more options

  • Yearly certification adjusted to a 3-year application process between payers and CMS for commercial value-based contracts to account for Advanced APM participation on behalf of included clinicians
  • Oncology, and cardiology programs likely to develop in mandatory models that were previously rolled back

MIPS Cost weight increases from 10% in 2018 to 15% in 2019

  • Medicare Spending Per Beneficiary (MSPB) and Total Per Capita Cost (TPCC) continue without change
  • 8 new episode-based measures introduced with a 10 case threshold for procedural episodes and 20 for inpatient episodes
  • Set to increase to 30% by law

MIPS Promoting Interoperability scoring becomes more difficult

  • In 2019, the max PI score is 100, with 10 additional bonus point opportunities as opposed to the 155 possible points in 2018
  • The base/performance subcomponents within the PI category will be removed
  • Fewer overall measures will be available for reporting with four objectives:
    • e-Prescribing
    • Health Information Exchange
    • Clinical Data Exchange
    • Provider to Patient Exchange
  • 2015 CEHRT requirement stands (2015 CEHRT earned a bonus in 2018, it was not a requirement)
  • Sending and Receiving Transitions of Care measures consolidated with previous medical reconciliation measures

MIPS Quality Adjustments

  • Alignment with CMS’ Meaningful Measures Initiatives to focus on measures that:
    • Address high-impact public health areas
    • Patient-centered and understandable to patients
    • Outcome-based (Patient Reported)
    • Minimize administrative burden (through a preference for EHR-based measures)
  • Priority to continue Patients over Paperwork Initiative
  • Claims submission only available for small practices
  • Individuals and groups will be able to use multiple collection types
  • Opioid-related measures now added to high priority measures
  • CMS Web Interface reduced from 14 to 9 measures for MIPS Quality and Medicare ACOs
  • High priority-measure bonus removed from those using the web interface because they don’t choose their own measures anyways
  • Generally, fewer paths available to earn full credit with quality measures
  • Thresholds continue to become more difficult to meet

For further information, CMS recently released the following resources:

2019 QPP Final Rule

2019 QPP Executive Summary

2019 QPP Fact Sheet

SHP’s Performance Analytics services can help you better understand your data so you can ensure you’re meeting key performance indicators. Click here to learn more.

Why All Roads Lead to Network Adequacy

In recent years, the uneven playing field between the large carriers in Georgia and the rank and file physician practices across the state has become even more skewed toward these payers. More aggressive tactics have littered the physician landscape recently, such as the following:

• The frequent reissuance of physician fee schedules sent as opt out–no negotiation only notifications with small sample fees. Meaning the only option is an objection which is tantamount to termination.
• The use of carrier specific/proprietary CPT code weighting (RBRVS) designed to adjust provider fees with no negotiation or notification.
• The use of narrow network deployments to justify the creation of new sub-HMO networks designed to drive down provider fees via the threat of being left out of network.
• Offering the range of carrier networks as a block, such that, in order to access more favorable lines of business, providers are forced to participate in other networks at lower rates. Similarly, in many cases, the large carriers will not allow the termination of a single network offering without terming the entire agreement which locks providers in to unfavorable networks as well.

A number of coalescing factors have combined to allow for the landscape under which these kind of tactics are now available:

• Among the requirements by the state health benefit plan is to only accept offers from statewide networks. This locks out regional offerings leaving only the largest carriers in the state as available options, thus incrementing their already massive leverage even higher.
• National mergers now leave only 5 major carrier options in the state, 2 of whom have struggled to sell outside of Atlanta, thus increasing the payer blocks of business managed by the top 3.
• Little to no oversight by CMS for Medicare Advantage plan tactics and lack of jurisdiction by the state Department of Insurance over these plans.
• Continued acceptance of egregious tactics by the physician community who have come to expect the next shoe to fall when dealing with the large carriers. As such, organized push back has been limited to the point that it is cited as evidence of acceptance by the carriers on multiple occasions.

In this kind of environment, the obvious initial thought is to fight the good fight at the tactical level. The typical response is to engage each of the individual carrier adjustments to inform providers to educate themselves, formulate individual strategies, and develop grassroots response when necessary to address the barrage of issues. That said, given the seemingly never ending stream spewing from the carriers, it seems timely to stop and consider more sweeping and longer term solutions for providers facing these difficult tactics. In our mind, there are 2 main changes which could be implemented legislatively that would even the playing field and allow providers to protect themselves without having to turn to the governmental agencies for constant support:

1. Loosening the anti-trust requirements which forbid collective bargaining- Currently, carriers use their massive footprint to leverage large chunks of business in their dealings with providers. Meanwhile, the providers, as sellers of a service, are under stringent requirements to individually negotiate, protect rates from sharing, and avoid any sense of collective bargaining unless tough integration requirements have been met. While many groups have reached integrative status, it is a costly and time consuming process to develop and maintain. If federal legislation would allow for less invasive associational type collaboration to perform true collective bargaining, smaller providers without the means to support a clinically integrated operations would immediately have the ability to have their issues heard and negotiations taken seriously. Obviously, that requires federal legislative involvement, which is well beyond our current scope of influence. This brings us to item #2.

2. Implementing true network adequacy guidelines for all products offered in the state (Commercial, Medicaid, Medicare, or Health Exchange)- Nationally accepted guidelines for the adequacy of a network to serve its members have been previously developed by the Association of Insurance Directors. These guidelines have specific requirements of specialty providers, per amount of enrolled population, which could be utilized by Georgia to give teeth to the concept. By deploying specific requirements with real penalties, such as the inability to sell product if not met completely, carriers would be forced to comply with the standards. As an example, Ambetter was able to launch its health exchange product in the Savannah market with less than 5% of the local physicians upon initial go live. Under these new guidelines, carriers would be forced to engage the local providers to build a legitimate network prior to accepting membership. Also, in the instance of ongoing claims issues or reissued fee schedules, if the providers could invoke the threat of termination in a manner that comes with a credible threat of shutting down new sales or eliminating current coverage upon determination of network inadequacy, then there is little question that provider negotiations, renegotiations, fee schedule objections, and claims issue grievances would be dealt with under a more fair platform.

Network adequacy as a solution is only as effective as its oversight, therefore, we believe that we need not only legislation with specific, objective, and enforceable guidelines but also the empowerment of the Department of Insurance to effectively implement any new law. The DOI has been effective as a provider advocate in the past but has been limited in jurisdiction over plans which are anything other than fully insured commercial options. In our mind, their oversight needs to extend to all plans with teeth to enforce at all levels.

In summary, we believe that the landscape has been skewed in the carriers favor for far too long. While it is inappropriate to paint all carriers with the same brush, we do believe that some type of sweeping reset needs to occur to even the playing field. We believe that initial response starts here.