Third Party Payer Update – COLORADO

Third Party Payer Update – COLORADOThe Triple Aim:

  1. Improving the patient experience
  2. Improving the health of populations
  3. Reducing per-capita cost

The Triple Aim is on all the payer’s minds these days. These three tenants are now being woven into many of the decisions being made about cost, quality, reimbursements, network size, etc.   Using these three items in your contracting strategy will help your success. Measuring and being able to report your ability to positively affect these three goals will make your practice more valuable to the health plans.

The payers are continuing to engage in the soft-narrowing of their various networks, using the direction of member volume to leverage rates. The “Value Based” PCP relationship appears to be the primary mechanism of this process. Therefore a member is not a member until you have their benefits carefully verified.

These days your referral people need to take a couple of extra steps:

  1. Is the member eligible?
  2. Are we on the PCP and Members list?
  3. What benefits are available for this plan type, product type, etc?


Aetna is in the process of buying Humana.

Aetna is sub dividing its Medicare Advantage product into sub-groups – watch for proper referrals and authorizations!

Anthem is buying CIGNA. This is a huge merger and will require FTC approval. It will likely take a year or more to happen. The interesting thing about this merger is CIGNA is almost 100% self-funded (ASO) business. Anthem is currently about 50/50 self-insured and fully insured. They are capturing an enormous amount of the ASO business with this merger, an interesting reaction to the Affordable Care Act.

July 1 Anthem updated its RBRBS year to 2014 – The more recent RBRVS years tend to favor the E&M codes at the expense of some surgical procedural codes – watch your reimbursement!

Mergers – Is There Opportunity for Your Practice? Usually during merger activity the health plans want a stable network. There may be a time for each of these (four different major health plans) to take a look at better rates! They all react to these things differently, so we will all need to keep our ears to the ground and look for opportunity.

Colorado HealthOP – They have had an incredible increase in members this year as a partial result of very favorable rate filings with the state. It will be interesting to see their rate fillings and growth as the New Year approaches.

United Healthcare is updating their RBRVS year! They are also increasing their focus on the use of Out-Of-Network (OON) providers. If you are in-network but routinely refer to OON providers it is nearly impossible to increase your in-network rates. United appears to be following Anthem’s recent program to locate and weed out the use of OON providers.

Medicare and Orthopedics: Medicare has initiated an Orthopedics bundled program called Comprehensive Care for Joint Replacement (CCJR). This program requires 800 pre-selected hospitals in 75 areas of the country to participate. They call it a Bundled Program but really it is a form of Pay-for-Performance in which the hospital gets the money and makes the decisions. More to come on this!

ICD-10 – so far so good? We haven’t seen any wholesale issues just yet. If you are experiencing any trouble please let us know!