Regarding secret #1, the varying costs of similar services charged is certainly a consideration when selecting a provider; however, it seems that the quality of care should also be part of the analysis. How do you recommend incorporating both?

You raise an excellent point. In fact, quality of care should be a critical factor in selecting any healthcare provider. Price comparisons should not, by themselves, be the sole driver in selecting providers. While we are advocates for patients evaluating their providers (just like we evaluate our car dealership’s service department), current resources to present this sort of information are still evolving. The two best ways to gauge quality of care are a) getting referrals from other providers and b) getting referrals from other patients whose opinion you trust.

Absolutely. While the hospital’s non-Medicare Charge Master should remain constant, they will often negotiate different pricing strategies with PPO networks and reflect anticipated discounts on their bills. In some cases, they will price services on a flat rate per procedure or flat per diems. Some hospitals negotiate DRG’s (Diagnosis Related Groups) as their pricing tool. In other cases, they may issue percentage discounts off the Charge Master.

3.

We do not use Sentinel and therefore, cannot comment on their services. Keep in mind that some hospital auditors perform “bill review desk audits” where each line of a bill is scrutinized to check for billing inconsistencies and overcharges. These audits can typically be completed in a few days. When considered appropriate, auditors perform “onsite audits” at the hospital, reading doctor’s orders and nurse’s notes to verify that the bill reflects services rendered. This form of audit can easily take several weeks to complete and results can vary based on the skill and experience of the specific auditor.

It is either paid through the TPA or directly to the Behavioral Health Provider who is delivering the program. The pricing is based on the percentage of participants using antidepressants. It usually runs between $0.70 to $1.40 PEPM. The ROI on the cost of PIP in the first year (from reduced drug costs) is usually 300 to 400 percent.

Two ways – contact the Health Research Enhancement Organization (HERO) at www.the-hero.org or contact Interface EAP at info@ieap.com - 800-324-4327 and ask for Melissa Black.

Legal counsel has advised Interface that PIP falls under safe harbor provisions regarding non-discrimination issues for HIPAA.

Legal counsel has advised Interface that PIP does not violate any privacy issues under HIPAA and that PIP falls under safe harbor provisions regarding non-discrimination issues for HIPAA.

t-MAC is based on the maximum plan cost (drug cost + disp) per month (30-day) supply. The employee pays the balance of the Rx allowed charge. This is calculated automatically at the point of service (pharmacy counter) by the PBM claims system. Contact Dr. Curtiss directly for further explanation: fcurtiss@pharmacare.com or (361) 749-0482.

Leakage refers to out-of-network utilization. In this slide, we are suggesting that out-of-network usage is often much more costly to both the plan and the member. Therefore, we recommend that plans monitor the usage trends carefully and if they reach over 15% of all claims cost (or 5% when you take out charges for neurologists, anesthesiologists, radiologists and cardiologists) , you should carefully review the medical procedures and providers being used for out-of-network services and determine why members are choosing this option. Also, keep in mind that leakage can also apply for out-of-area/in-network services. That refers to facilities located outside your primary service area but still considered in-network by your PPO. Often, these facilities do not receive the same level of discounts as those in your primary service area.

Can we get a copy of this presentation?

Sure. Simply click on one of the links at the top of this page. The archive is a complete replay of the event. The slides are a PDF version of the PowerPoint that accompanied the presentation.