In another example, researchers in India conducted an experiment that introduced a
third-party payer, with encouraging results.
"The decision tree starting at the intake to care is so important," Lloyd stresses, noting that although many providers may be used to complying with state credentialing, care, and performance standards, states rarely enforce these standards--and the funding that is tied to them--the way that MCOs, commercial insurers or other
third-party payers do.
Once the cheaper generic becomes available, the laws of most states and the pharmacy reimbursement policies of most
third-party payers result in virtually automatic substitution of the generic drug when the brand drug is prescribed.
* Requiring
third-party payers to program new vaccine CPT codes as soon as vaccines are approved by ACIP/AAP or face large monetary penalties.
Throughout the years, ENTs have tried to keep pace with reimbursement requirements, but we are constantly outmaneuvered by the
third-party payers' technology.
The problem is exacerbated in medical practices by the fact that the receivables from
third-party payers will generally be collected at a lesser amount than the total charge.
"Since patients do not pay directly for most off-label uses,
third-party payers have become crucial for market access," says Joshua Cohen, the study's lead investigator.
Direct electronic communication with
third-party payers can shorten claims turnaround time, improve claims accuracy and increase cash recovery from payers for previously denied claims.
Unfortunately, the
third-party payers have arbitrarily decided not to provide reimbursement for PET studies done for tinnitus.
Once the facility achieves that level of operations, it must evaluate its ability to reduce cost to remain competitive for new admissions that are restricted by predetermined charge structures established by
third-party payers.
"The Managed Care Connection program helps these retailers maximize their relationships with
third-party payers," Williams explains.
My practice evolved because of an increasing loss of autonomy, which led to tremendous aggravation that stemmed from inherent conflicts of interest with
third-party payers. Declining reimbursement rates and unbelievable hassles with the insurance industry were a part, albeit a small part, of my reason for going to a fee-for-service practice.
