ROANOKE TIMES
Copyright (c) 1996, Roanoke Times
DATE: Sunday, July 14, 1996 TAG: 9607120026
SECTION: BUSINESS PAGE: 1 EDITION: METRO
COLUMN: Health Care
SOURCE: SANDRA BROWN KELLY
Sometime in the next few days, Trigon Blue Cross Blue Shield will print 90,000 copies of a new pamphlet titled Provider Reimbursement Arrangements. The publication explains the many ways Trigon pays doctors in its networks and is a good roadmap for how physicians are paid by all insurers.
Trigon will begin mailing copies to customers who are getting insurance benefit cards this month, said spokeswoman Brooke Taylor. Trigon has been really alert to the new legislation; as of Tuesday, it also was the only insurance company to have filed appropriate information with the state about its networks.
The Trigon pamphlet is a reaction to House Bill 1393, which became law on July 1. The bill directed insurers to have a procedure for telling purchasers of health care the kinds of financial arrangements insurance companies have with doctors and other care providers in their networks.
HB 1393 did several other important things, too.
For patient protection, it said:
* An insurance plan must be in understandable language.
* A patient must be notified if his or her doctor has been terminated from a network, and then be allowed to continue with that doctor for 60 days unless the doctor was terminated for cause.
* Once a year the insurance company must give its customers a list of providers, indicating which doctors are not accepting new patients.
* Insurers can't forbid doctors from telling patients about all treatment plans even if the insurer doesn't consider the treatment appropriate or pay for it.
To help the doctors, HB 1393 directed that:
* Primary care physicians must be given reasonable notice of the termination of a specialist.
* A doctor can't be required by contract to give up the right to sue an insurance company.
* An insurer must file with the Department of Health Professions notice of its intent to form a provider network so that all providers in an area can learn the terms of the network and have an opportunity to apply to join.
One of the drawbacks in the new law is that it affects only insurance plans covered by state regulations, or about half of the people insured. Self-insured companies, which include most large employers, are exempt from the legislation. So are doctor groups that set up their own networks and market them directly to employers.
Also, HB 1393 has no provisions for enforcement, except by taking complaints to court.
Still, the bill is a "great beginning," said Roanoke opthalmologist Dr. Ken Tuck, president-elect of the Medical Society of Virginia.
Tuck pointed out that much of the original language of HB 1393 didn't make it through the legislative gantlet. He said, too, that he was disappointed that the legislation didn't include a provision requiring insurance companies to say how much of the premium dollars are spent on patient care.
But he also was pleased that the bill instructed the Joint Commission on Health Care to study the effects of a "point-of-service" law that would require insurance companies to allow a subscriber or customer, for a reasonable fee, the option to choose a doctor outside a network.
Generally, HB 1393 laid groundwork for a seemingly friendlier atmosphere in the realm of managed care.
"We couldn't hope to get the whole package through at once," Tuck said.
If nothing else, other companies, even companies not required to inform its subscribers, might decide to produce and distribute a pamphlet like Trigon's. And now that the subject of incentives is open, perhaps doctors will feel comfortable discussing reimbursement methods with patients.
Just knowing the right language is a start. Trigon's definitions of the most popular pay arrangements, which accompany this column, are an excellent start.
And now that we have the language, we can ask the questions, and that could be HB 1393's best accomplishment.
Sandra Brown Kelly covers health and medical issues for The Roanoke Times. You can reach her at 1-800-346-1234 outside the Roanoke Valley, or at 981-3393 or through e-mail to biznews@roanoke.infi.net.
WAYS DOCTORS AND HOSPITALS ARE PAID
nFee-for-service - Generally an agreed-upon, discounted fee.
nPerformance Extra - Incentive program for rewarding primary care physicians based on measurements that include patient satisfaction and complaints, medical record reviews, willingness of a physician to accept new patients, and the measurement of a physician's utilization level compared to other doctors based on the health status of a physician's patients, and the pattern of referrals.
nPer case/per confinement reimbursement - A fixed dollar amount for all covered medical service during treatment of a particular illness, diagnosis or confinement.
nPer diem reimbursement - Fixed dollar amount per day for all covered medical services regardless of amount of care provided.
nPercentage of covered charges - Agreed upon percentage of actual charges
nProvider incentive payments - Payments for managing patients' care so that cost of services provided falls below certain agreed-upon costs.
nEpisode of care - A provider is paid a fixed amount for treatment of a specific illness, conditions, surgery and is responsible for using payment to cover all expenses. A fixed fee for hip joint replacement would have to cover the surgery, anesthesia, radiology, hospitalization and everything else.
nCapitation - A specified amount per patient per month no matter if the patient doesn't visit the doctor that month or visits the doctor several times.
Source: Trigon spokeswoman Brooke Taylor
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