Private Payers Make More Policy Changes Outside Provider Contracts

Starting Oct. 1, Anthem Blue Cross is increasing the penalty for hospitals that miss the notice deadline for emergency admissions. Hospitals that fail to inform the commercial insurer of emergency admissions by a deadline set forth in their manuals will lose 50% of their reimbursement, according to a change in its policy.

That’s the latest example of payment policy changes that commercial payers and Medicare Advantage plans are using to drive down payment rates to hospitals without modifying their contracts, according to attorneys and physician advisors. UnitedHealthcare also just announced its “site of service” policy for outpatient surgeries covered by commercial plans. Effective Sept. 1, United said it’s conducting medical necessity reviews to determine whether procedures should be performed in hospital outpatient departments, noting that UnitedHealthcare members “may choose” to have procedures at ambulatory surgery centers (ASCs) or elsewhere. Physician advisers also report they are struggling with Medicare Advantage (MA) plans that authorize observation stays instead of inpatient admissions without acknowledging they are denials, and because they don’t technically deny the admission—they unilaterally change it to observation—hospitals may have a hard time getting paid for medically necessary admissions (“Some Payers Approve Observation Over Admission Without Denials; Arbitration May Help,” RMC 27, no. 21).

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