Health Insurance Industry Issues and Legislation

In 2018 DaVita sued the Marietta Memorial Hospital Employee Health Benefit Plan claiming the Plan violated the Medicare Secondary Payer Act ("MSPA") by providing limited coverage for outpatient dialysis. In a newly released decision, the U.S. Supreme Court sided with the Plan, holding that its coverage terms for outpatient dialysis do not violate the MSPA because those terms apply uniformly to all covered individuals.

After a short qualification period, for ESRD patients accepted for coverage under Medicare Part B, Medicare is the secondary payer for 30 months. Plans may adopt cost containment strategies such as network carve-outs and Medicare reference-based pricing. Potential savings can be close to a million dollars or more. Unlike some companies, HHC charges only a low flat per treatment fee instead of a percent of savings for repricing ESRD treatment claims maximizing client savings.

Commercial payments tide to Value-Based Care (VBC) arrangements has grown by 500% since 2012. VBC incentivizes providers for following preventative and interventional best practices, using resources efficiently, and avoiding adverse outcomes. So far, results based on outcomes and cost efficiency have been mixed.

The only thing keeping healthcare industry prices from outpacing today's roaring consumer inflation is the lag effect. Typically, healthcare prices, reimbursement rates and labor contracts are set 2 or 3 years in advance. But with provider salaries and supply costs surging, healthcare industry inflation will outpace consumer inflation again for years to come.

That's why more and more payers are turning to HHC Group to find every dollar of potential savings. They're maximizing their savings by having HHC negotiate and reprice their out-of-network claims, conduct line-item reviews or taking advantage the HHC's Referenced Based Pricing model that best meets their needs.