You are currently browsing the tag archive for the ‘insurance regulation’ tag.

Part Three – Payment Reform: About More Than Just Dollar Signs


The final NCQA PCMH joint principle encourages appropriate payment that “recognizes the added value provided to patients who have a patient-centered medical home.”  In addition to the PCMH, Accountable Care Organizations can provide physicians with a payment structure that is financially rewarding, as well as efficient and unburdensome.

The following points highlight what is needed to ensure that primary care providers are reimbursed for delivery care in an adequate manner:

Billable Time

Payment for calls and emailing saves time and money for both the patient and the doctor if a face-to-face consultation is not necessary. Dr. Casalino says, “As long as practices are paid primarily for services provided by physicians during in-person visits, it will not be possible to fundamentally change the way physicians spend their time.”


Maryland HB 435 (enacted May 20, 2010) – requires health insurers to pay a bonus to PCPs for services provided after office hours.

Virginia SB 675 (enacted April 7, 2010)– requires health insurers to cover telemedicine services.


 Standardization of Claims

A recent Health Affairs article finds that on a national scale, a single transparent set of payment rules for multiple payers, a single claim form, and standard rules of submission would translate into $7 billion of savings annually for physician and clinical services. Four hours of professional time per physician and five hours of staff time could be saved each week.


Colorado recently enacted several bills (HB 1004, HB 1330, and HB 1332) to begin standardizing claims.

West Virginia enacted similar legislation (SB 665) on March 11, 2010.



While providers must submit claims within a certain period to be reimbursed, insurers often deny claims or claim to never receive them, placing the burden on physicians to monitor and resubmit paperwork.


Connecticut enacted HB 5303 (enacted May 5, 2010) – requires all managed care organizations to report claims denial data, which is posted on the state’s Department of Insurance website.

Vermont HB 444 (enacted June 2, 2009) – requires payers, within 30 days of receiving a claim, to send payment or to provide notice of why the claim is contested or denied.


In a Maryland State Medical Society survey of members, 95 percent said health insurance protocols had a somewhat or very negative effect on the doctor’s ability to treat patients, with nearly 19 percent of participants spending 150 hours per month interacting with carriers. The organization’s report concluded “hidden costs [are] missed opportunities: every hour a skilled provider spends on administrative tasks associated with insurance protocols is an hour not spent on patient care.”


While the federal health reform bill and recent state legislation provide opportunities to test different payment models, testing the feasibility of varying billing requirements is also needed to improve the primary care workforce.


Additional resources on payment reform

Harold D. Miller’s Ways to Facilitate Better Healthcare Payment and Delivery Systems and Lower Healthcare Costs

The Commonwealth Fund’s Developing Innovative Payment Approaches: Finding the Path to High Performance

AMA payment resources



Please feel free to leave comments, rate posts, or suggest topics.


Enter your email address to subscribe to this blog.

Join 1 other follower

Twitter Updates

Recent Comments

Dr. Miller on Variations in How States Prepa…

Join my bloglog community

Join My Community at MyBloglog!