The Health Care Negotiator

May 20, 2019

By: Allison Bell
Featured on lifehealthpro.com

A professional health care price gladiator says negotiating conditions seem to be about the same as they've been for the past 20 years, when he first climbed into the arena.

Prices continue to be all over the place, and the providers' willingness to bend on price also continues to be highly variable, according to Bruce Roffe, president of HHC Group.
"You can never know what a provider's going to do if we've never called them before," Roffe said in a recent interview.

HHC can help a health insurer, self-insured health plan, workers' compensation plan or other entity review medical bills, manage cases and dicker with providers over the cost of out-of-network care.
The firm can also look at care from another angle, by acting as an external independent organization. When HHC fills that role, it helps patients and coverage providers determine whether a plan or prepaid health care services provider, such as a health maintenance organization (HMO), is providing enough of the right kind of care.

Some providers hope HHC will help them get paid more quickly, Roffe said. Others prefer to stick to their billed prices and turn any unpaid bills over to collection agencies.

When HHC is conducting negotiations over out-of-network bills, the firm uses a combination of commercial physician services price data and its own proprietary data.

Roffe said the reasonableness of the commercial "reasonable and customary" price figures varies from case to case. For HHC, newer numbers are better than older numbers. Numbers that come from the prices plans actually paid are better than numbers based on what the providers billed.

Providers in competitive markets tend to be more flexible than providers who have rural markets all to themselves.

In most markets, providers tend to be tougher about prices early in the year and looser later.
Roffe said he is seeing some change in HHC's base, with more employers with 10 to 100 covered lives asking for help.

"You have more small self-insured groups," and those small groups have a strong incentive to do what they can to get prices down," Roffe said.

Roffe said he thinks the best way to fight high health care prices is to push ahead with efforts to develop well-designed HMOs, strategies for paying providers flat fees for each patient served, and paying a single price for a bundle of closely related services. But he said replacing the current fee-for-service system with different structures, such as HMOs, could lead to new types of problems.

"HMOs aren't for everybody," Roffe said. "Not all of them are the same."

Canada has tried to be strict about managing access to care, and the result is that many Canadians come to the United States to get care, Roffe said.