Payers Divide and Conquer Tactics in 2009-2010

In 2009 insurance payers became more brazen in their delay and deny tactics with providers and their increased premiums. Some of their tactics appear to be an effort to drive a wedge between providers and their medical staff. This was their response to what clearly looked like a dramatic change in the structure of healthcare in the U.S. Many would have expected a more congenial politically soothing approach from them. Did they know something we didn’t or were they simply scrambling to hoard every last dollar they could before the axe fell? What will happen now that the axe no longer is evident?

Some of the new tactics employed by payers using their increasing war chest has a potentially disastrous implication for free standing psychiatric facilities. Have you noticed what seems to be an increase in authorization requirements? Some payers have instituted a policy that seems to impose a peer to peer requirement on admission. Other payers instituted a short time window within which provider’s physicians must call, making it difficult at best to manage the morning after a busy night.

The immediate impact of these changes are an increase in denials resulting in delays in payments and greater pressure (time and other) on your referring MD’s. Apart from the immediate adverse impact on your cash flow, there are strategic issues to consider with your medical staff:

• Is it likely that your referring MD's reduce the number of admissions because of the added time and headaches imposed by the payers’ tactics?
• Are any key referring MD's likely to consolidate patients in one facility?
• Do any Major Medical facilities in your market area have a psych unit with a psychiatrist on duty at all times?
• Have you experienced friction with your MD's due to your added needs and their more restricted time limitations?
• Are you tightening your admission requirements to avoid cases most likely to be denied by payers? For example, restricting frequent readmit patients because the payers have labeled them “chronic” and/or will not pay for LTC that clearly is needed.

ARA is available to help you with the backlog of appeals as well as to tackle identifiable patterns of abuse by payers. Our success in winning appeals and getting cases before the proper authorities, even when there appears to be no viable options left, makes us a valuable partners for your hospital.

ARA’s staff is also experienced medical staff relations and practice management. We can work out solutions between you and your medical staff to not only counter the payers’ “divide and conquer” tactics, but to make your facility the one of choice in your market place.