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| Sample Newsletters | MarketPlace AIS Products & Services |
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Health plans argue that their usual, customary and reasonable (UCR) rates are fair and that they shouldn’t be required to accept any fees that out-of-network providers wish to charge. But they face an uphill battle in convincing courts, state regulators and now Congress that their use of Ingenix data did not keep rates artificially low. And lawsuits are extending beyond UCR rates, with some long-pending “prompt-payment” class-action suits given new life by the Ingenix cases. Increased scrutiny of Ingenix data recently changed the focus of a prompt-pay class-action suits involving three Florida health plans. But strategies exist that will help health plans minimize these financial and legal risks. Listen in and discover:
EDWARD KAPLAN is senior vice president, national health practice leader in The Segal Company’s New York office. He joined Segal as a managed care consultant in 1993 and in 1996 was promoted to vice president, and became national health practice leader in 2001. Mr. Kaplan has worked with managed care programs since 1986, with special emphasis on pricing and plan design strategies for managed medical, dental and prescription drug programs working with national and local corporations, governments, and collectively bargained plans. He created the Segal Health Plan Trend Cost Survey in 1996, now a standard in the industry. MATTHEW KATZ is executive vice president/executive director of the Connecticut State Medical Society, the state’s largest physician organization, founded in 1792. He also is the former director of private payer advocacy and director of the Practice Management Center at the American Medical Association (AMA). Mr. Katz previously served as strategy manager for AMA’s Private Sector Advocacy unit, and as a senior health policy associate in health policy development. Prior to his arrival at the AMA in 1998, he was a financial analyst in the department of managed care at Northwestern Memorial Hospital, where he analyzed the hospital’s case-mix database and provided insight into the potential profitability of managed care contracts and specified services. He also worked for Medica Health Plans of Allina Health System and UnitedHealth Group. Moderator: Steve Davis, managing editor of AIS’s Health Plan Week
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