Closing the loop holes and limiting the options....

Over the last several years, many healthcare providers chose not to contract with some health plans because they could not negotiate fair rates. The "out-of-network" strategy worked for years and in some cases was very lucrative for some. Unfortunately, all good things eventually end. Health plans are closing their networks by limiting benefits when provided by non-contracted providers.  There are a variety of ways that they do this, but all involve shifting more financial responsibility to the patient. The Blues and some of the other large plans have implemented daily limits of $380, $500, $540 and $600 for services provided by non-contracted providers.

The limit is often regarded as a "punitive cap" and to some extent that’s what it is. People often hose PPO plans because they want more choice and power to direct their care.  While PPO members still have the power to choose it comes at a much higher cost, hence the term punitive cap. Consequently, many patients are chosing to be treated by a contracted or preferred provider.

What to do?  This is the time to do a little marketing and education. For instance when negotiating a contract be sure you tell the health plan representative what you can do for them to lower their cost of care.  Many Ambulatory Surgery Centers (ASCs) compete directly against hospitals for the same services.  If you can offer competitive pricing for the same quality of service, you just might get their attention. With technology advancements, more and more procedures can be safely done in an outpatient setting.  Work with your physicians to establish programs for services traditionally done in an inpatient setting.  Then market them to both employer groups and patients.