Health Care Contracting and Negotiation: What does this mean to the consumer?
September 8, 2014

Natalie Harms, PT, MPT, DPT, GCS

There has been much press lately regarding the lack of resolution between Blue Cross Blue Shield of Nebraska and Alegent Creighton Health (now called CHI Health) or UniNet Healthcare Network (the contracting agent for Alegent Creighton Health, now CHI Health). The current challenge is that Blue Cross Blue Shield believes that healthcare can be provided for lower cost, and CHI Health believes that high quality care may cost more.

Over the past several decades health care insurance has advanced to be more comprehensive, as compared to policies of the past that were more geared toward major medical or medical emergencies. The responsibility of the patient, the provider and the payer has taken on new meaning with advancements in health care insurance.

Traditionally the patient sought insurance, the health care professional provided care, and the insurer/payer paid what the provider charged. Over time this system wasn’t as effective due to the potential of misuse, and high cost. Insurers began to negotiate with the providers in an attempt to control health care costs, and focus on a more comprehensive product. It was at this transition that the patient began to lose input regarding care, as well as choice of provider.

Currently, providers must contract with most insurance companies. Through contracting, reimbursement rates are determined based on what care is provided. This is called fee for service. In physical therapy, similar to your medical doctor, charges occur for each component or type of treatment that is administered.

There are some insurance companies that pay a flat rate for treatment. In this scenario, one payment is reimbursed regardless of treatment on a specific day.

In addition, some insurance companies are forming alliances with health care systems to control care and may restrict your choice. An example of this is UniNet Healthcare Network (or CHI). UniNet controls the physical therapy market for United Health Care insurance in Douglas County. This means that UniNet, not the doctor, the patient or even the insurance company, determines what physical therapy providers can be in network or must be out of network for United Health Care. In this scenario the patient loses most input regarding the type of physical therapy provided as well as who can provide it.

Just as UniNet is the contract negotiator for CHI Health, health insurance is a patient’s contract negotiator. They try to negotiate the best product for the best price. The focus needs to be on affordable health care. In the future it is likely that reimbursement methodologies will evolve, that payment will be related to outcome. All health care providers are capable to make this change.

What can you do to represent yourself in the health care, health insurance continuum?

• Work with your employer on employer based insurance, or broker to assure that the type and freedom of choice of care is the broadest.
• Educate yourself regarding the different types of insurance policies and related costs, and then choose what is best for you and your family.
• Communicate with your health care provider if you have questions about what costs are associated with your health care.
• If working with the health insurance marketplace, choose policies that provide the most flexible plans, with transparency and choice of provider.
• Communicate with your legislator when issues arise that impede your access or ability to use your plan.
• In the physical therapy world, work with independent private practices which provide high level of care managed by your physical therapist, for the least cost to you.

Unreasonably high cost health care negatively impacts all of us. Whether it is through your co-pay or co-insurance, if your insurance company is paying more than a reasonable cost for health care it impacts the cost for everyone.

One of the greatest attributes of being an American is freedom. Freedom of choice, especially when seeking healthcare, should be a right that is protected.

At Makovicka Physical Therapy, we are in network providers with Blue Cross Blue Shield of Nebraska, and are happy to help you with any physical therapy needs you may have. Please visit our website at makovickapt.com for the closest location to you.

The Makovicka Difference

We are leaders in our profession, locally owned and operated by physical therapists who forge relationships with patients, and advocate for their care. All of our clinics have board-certified specialists on staff, meaning you get the highest level of care to maximize your recovery, and get you back to your game. We will listen, evaluate your symptoms, and create a personalized physical therapy program to meet your needs and improve your function, strength, and mobility.

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