Tag Archives: Payer

Medical Payers by Total Enrollment

We all know the big names in the health insurance market but do we know how many millions of members they cover?  This article breaks it down by the top 10 payers:

1. United Healthcare — 47.53 million members

2. Anthem (Indianapolis) — 33.99 million members

3. Aetna (Hartford, Conn.) — 19.96 million members

4. Cigna (Bloomfield, Conn.) — 14.03 million members

5. Humana (Louisville, Ky.) — 9.66 million members

6. Blue Cross and Blue Shield of Illinois (Chicago) — 8.09 million members

7. Kaiser Foundation Health Plan (Oakland, Calif.) — 7.81 million members

8. Health Net (Los Angeles) — 6.12 million members

9. Blue Cross and Blue Shield of Texas (Richardson) — 5.02 million members

10. Centene (St. Louis) — 4.51 million members

Top 10 Health Plans that are also Providers

One of the shifts currently happening in healthcare in healthcare is the blurring of the lines between the previous silos that separated providers and vendors.  Now, payers are buying providers and therefore becoming providers and more and more providers are becoming payers.  Talk about blurred lines!  Here is a listing of the top 10 health plans that are provider sponsored.  An Axiom client, Presbyterian in New Mexico, has made this list.

Population Health is Evolving in the Ever-Evolving Healthcare Landscape

With the changing healthcare environment, the traditional silos of the healthcare system (e.g. payers vs. providers) no longer works.  Whether these two typically opposing entities like it or not, they have to come together in order for the common goals of better healthcare and health outcomes along w/better quality and cost controls for everyone.  As we all live longer and have to deal with more chronic versus acute conditions, payers and providers have had to ramp up their respective population health programs.  In the past, it has been seen more from their particular vantage points from the payer/provider lens, but increasingly in shared-savings arrangements and landscape such as ACOs and Patient-Centered Medical Homes, these walls are coming down.  Read here how some of this is happening.

Part 2: ICD-10 and What Providers Should Know About Payer Remediation Activities

I have been following ICD-10 related information and news sources for a period of time.  Like any good informed person, I try to be cognizant about not having my blinders on and only focusing on a single source or even a single view of ICD-10.  This means that I should not exclusively focus on payer-related sources for my information although my current assignment is with a payer and most of my professional experience is in that sector of healthcare.  Below is a summary of what I, in my humble opinion, wish providers could know about a typical payer’s ICD-10 impacts and remediation plan.  Please note: I typically am addressing smaller professional provider practices and rural and safety hospitals in this.  I have found that large health systems and hospitals have a good grasp on their respective ICD-10 projects and are in fairly good shape overall with meeting the 10/1/14 compliance date.

1.  Professional providers are reimbursed based on CPT-4/HCPCS codes and not using ICD diagnosis codes.  As mentioned in the previous blog post, Part 1 ICD-10 FAQs and Common Misconceptions, CPT-4/HCPCS codes are governed by the AMA and are NOT being impacted by the move to ICD-10.  However, this doesn’t mean that the move to ICD-10 may not impact overall claims processing, though.  Diagnosis codes most likely are used during benefits assignment during the adjudication process at a payer, e.g. maternity benefits for an office visit.  Depending on how granular the payer was in their configuration will most likely determine how the claim may or may not be affected when ICD-10 codes are introduced on a claim.

2. Impact to individual provider contracts.  There may some provider contracts, that specifically call out certain CPT-4/HCPCS codes billed in conjunction w/a certain diagnosis code range to be reimbursed at xxx dollars.  I have seen an example where certain outpatient office visits for members diagnosed w/HIV/AIDS get paid a certain rate.  However, most payers are trying to phase out the use of this because it turns into a maintenance nightmare.  Most provider contracts renew yearly and most payers have thousands of provider contracts in place at any given moment.  Also, CPT-4/HCPCS codes as well as ICD codes get reviewed and updated each year.  That means that these contracts that have an expired code has to be located, remediated w/the updated code, and then some form of updated contract sent back out to the provider.  Depending on how the master agreement is setup between the  payer and provider, this may have to go through a formal contract negotiation process—AGAIN.

3.  Pre-authorization policies.  Most authorizations policies (for outpatient services or procedures) are based on the CPT-4/HCPCS of the procedure and not the ICD diagnosis code.  Remember, the diagnosis code typically represents the medical condition.  For example, when a provider calls the payer asking for an authorization for, say, whirlpool therapy, the call agent at the insurer will look up CPT code 97022 and find out whether a pre-auth is required.  If it is, then medical necessity will be performed to determine if the member’s medical condition (as denoted by diagnosis code) warrants this treatment.  In this case, the member has a hip joint replacement (ICD-9 diagnosis code V43.64) and the pre-authorization nurse approved the provider’s request.

4.  Provider must provide the ICD-10 code!  Some providers (and even some folks on the payer side) are under the impression that come 10/1/14, payers can ‘cross-walk’ ICD-9 codes over to ICD-10 codes.  Or a provider calls for an authorization but only gives the description for the patient’s medical condition instead of the diagnosis code.  Payers (shouldn’t, anyway) pick and choose the ICD-10 diagnosis code for the provider.  It not only is against industry guidelines since the medical condition given to the payer has to be supported in the patient’s clinical record, it also sets a bad precedent for the provider in not giving them much of an incentive to learn and use ICD-10.

What are some of your thoughts, either on what providers are wanting to know from payers or other topics that payers should be communicating to providers?