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Most of us give no thought to how our medical providers are reimbursed.  We go in for services, pay what we are told and then deal with any balance billing that arrives in the mail at a later date.  We may complain about the cost of our services, but rarely do we think much beyond that.

Recently the Federal government, through Medicare reimbursements and the Affordable Care Act, are working to impact the cost of healthcare in this country.  Carrots and sticks are being applied to all players including providers, insurance carriers and insureds.  What does this mean and how will it affect us?

We have all seen that Medicare has consistently negotiated hard-won contracts with providers reducing payouts each year and that private insurance companies are following suit.  What we may not notice is that the objective of Medicare Advantage plans and many under-65 health insurance plans is to manage the care provided to members while trying to look attractive with extra perks not traditionally covered.

So, what does “managing care” mean?  The positive objective of this management is to monitor treatment of medical conditions and measure outcomes.  Did the patient have the improvement in health expected or did particular treatments fall short of their target?

The negative result of this management is that not all treatments that the patient or the provider feel are appropriate will be approved.  What recourse do patients have when the insurance carrier refuses to pay for services?

We now hear that, rather than reimbursing providers for the services provided, payouts will be increasingly based on predetermined positive outcomes of care.  If a patient has to continue treatment because what was done was not effective for a particular condition, the provider will not be paid above the fixed fee negotiated. Will the patient be able to get the follow up services needed, or will we all be at risk of “holding the bag” on completing our treatment?

There are no easy answers, but it will become increasingly critical that we take better care of ourselves and do what we are told when we are discharged from a provider.  If our lack of compliance causes us to miss the outcomes we want, additional treatment costs may very well be our personal responsibility.

Do you need help navigating the ever-increasing complicated system? CDA Inc is here to help you!