Dec 21, 2016 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Pathology
Local medical labs and pathology groups are often excluded from narrow networks. Thus, another round of “network provider reduction” is a serious issue
Total enrollment in health insurance products may be increasing, but in its recently-issued study, McKinsey and Company determined that the Health Insurance Marketplace (Health Exchange) is shrinking even as the number of enrollees continues to rise.
The development is unfavorable to the nation’s clinical laboratories and pathology groups because fewer health plans on the exchange means less access to patients. It also means that the remaining health insurers are taking steps to further narrow their existing networks in order to curb expenses by limiting options.
The new report published by McKinsey and Company reveals that insurers are moving towards plans that offer fewer options for consumers, mostly due to losses suffered on the health exchanges. The report, titled, “2017 Exchange Market: Plan Type Trends,” states that in 2017 a majority of the healthcare plans (about 75%) available to consumers under the Affordable Care Act (ACA) will be Health Maintenance Organizations (HMOs) and other similar limited-option plans, such as Exclusive Provider Organizations (EPOs).
EPOs are a hybrid of HMOs and PPOs and share some common options from both. Of the states investigated, McKinsey found that about 15% of customers eligible for ACA exchanges will have no PPOs available to them. (more…)
Sep 28, 2015 | Coding, Billing, and Collections, Laboratory Instruments & Laboratory Equipment, Laboratory Management and Operations, Laboratory Pathology, Laboratory Testing
As national health insurers push more risk to hospital systems and medical groups, many hospital administrators become more interested in establishing their own health insurance companies
New modes of provider reimbursement—such as bundled payments and budgeted payments—are motivating hospitals and health systems to reconsider their existing relationships with health insurers. Hospital administrators want to control the dollars they save by improving patient care, instead of allowing insurance companies to capture that money.
To accomplish these goals, more and more hospitals and health systems across the country are making one of three moves:
• Funding their own health plans;
• Partnering with health insurance companies; or,
• Buying health insurance companies.
As this trend gathers momentum, it will put the medical laboratories of hospitals in a much better position to regain access to patients. It can be expected that hospital administrators will include their own clinical laboratories and anatomic pathology providers in their own health insurance provider networks. (more…)
Jun 17, 2013 | Compliance, Legal, and Malpractice, Laboratory Management and Operations, Laboratory News, Laboratory Pathology, Management & Operations
As ACO movement gathers momentum, hospitals and health systems see opportunities in providing health insurance
Hospitals and health systems are getting back into the health insurance business. Not only is this seen as an opportunity created by the development of accountable-care organizations (ACOs), but it may help the clinical laboratories of these same hospitals that serve office-based physicians in their communities.
This trend is another result of the Obamacare legislation. Some hospital systems are seizing an opportunity to expand their roles and grow revenue by once again getting into the health insurance business. Some experts believe this trend is likely to create more competition among insurers.
It may also accelerate the shift away from fee-for-service reimbursement to a global or bundled payment structure. As this occurs, medical laboratories will need to develop services that offer greater value to physicians and patients. (more…)
Nov 9, 2012 | Laboratory News, Laboratory Operations, Laboratory Pathology, Management & Operations
UnitedHealth’s acquisition of Brazil’s Amil is another example of healthcare’s globalization and may open door for clinical laboratory acquisitions in Brazil
UnitedHealth Group (NYSE: UNH) is buying an HMO in Brazil. The two players are the largest insurers in their respective countries. For pathologists and clinical laboratory professionals, this merger demonstrates that the trend toward globalization of healthcare—including laboratory medicine—continues one step at a time.
Brazil’s Growing Middle Class Drives Demand for Coverage
On October 8, 2012, UnitedHealth announced in a press release that it would pay $4.9 billion in cash to acquire a 90% stake in Brazil’s Amil Participacoes S.A. (BM&FBOVESPA: AMIL3). Amil is Brazil’s largest private insurer and operator of health clinics. The company provides health benefits and services to more than five million people. (more…)
Mar 28, 2012 | Laboratory Management and Operations, Laboratory News, Laboratory Operations, Laboratory Pathology, Managed Care Contracts & Payer Reimbursement, Management & Operations
NCQA published annual report showing increased rates of screening for most of its HEDIS quality measures and medical laboratory testing often plays a role in these screening activities
For almost a decade now, clinical laboratories and pathology groups have been asked by many private payers to provide laboratory test data for a number of clinical services. In turn, these private health insurers annually submit this data to the Healthcare Effectiveness Data and Information Set (HEDIS) program managed by the National Committee for Quality Assurance (NCQA).
Although their medical laboratories regularly feed this data to payers, few pathologists or lab administrators track how HEDIS data is used by NCQA. Thus, it is useful to know that, over the years, HEDIS data provides evidence that better utilization of certain clinical laboratory tests by physicians directly contributes to measurable improvements in patient outcomes across the United States.
(more…)
