After months of touting the transparency of health reform negotiations, Congressional leaders retreated behind closed doors to start the task of merging together the five major healthcare reform bills that have passed out of various Committees. As healthcare annual spending tops $2.4 trillion, the stakes are high as Congress faces conflicting pressures to expand coverage and curtail spiraling costs.
A handful of major issues and many smaller ones remain unresolved. The two chambers disagree on how to pay for the legislation, with the Senate preferring a tax on high-value insurance policies as the main revenue-producing measure, and the House favoring a surcharge on millionaires. Liberal Democrats want to penalize companies that do not provide coverage to their employees; moderate Democrats would take a less punitive approach. And many lawmakers are concerned about the affordability of insurance policies Congress would require people to buy under an individual mandate.
So the question remains– can consensus be reached in a Congress that remains sharply divided on the details of reform?
A Closer Look at the Debate
In the House
Leaders in the House have proclaimed they can produce a public plan using Medicare rates, but it is unclear they really have the 218 votes required for such an approach. On the other hand, the Medicare for Everyone, or “Medicare Part E,” rebranding of a public option has managed to sway at least some moderate House Members, as has confirmation of a deal struck in the Energy and Commerce Committee to eventually increase Medicare rates in rural areas. What is clear now is that a “robust,” federally-administered, nationwide public plan will be included in the House bill.
The House does intend to include some of the “fees” initially proposed in the Senate Finance bill, with keen focus on the medical device fee. We understand that Speaker Pelosi told concerned Members that the House tax would be $20 billion, assessed to profits (rather than fees assessed to all revenues, as in the Senate bill).
Without a pathway to a final bill or comprehensive Congressional Budget Office (CBO) scores, House floor action appears unlikely before the week of November 9. Given its ability to move legislation more quickly, however, the House could be on the floor as late as the week of November 16 and still pass their bill prior to Thanksgiving recess.
In the Senate
Progress in the Senate continues at a slow pace. Despite positive statements by principals, negotiations at the staff and Member level have been difficult and sometimes contentious. While no “deadline” for the talks has been set, leadership has privately directed that final legislation be scored by the CBO and ready for the floor by November 9. Several key staff are increasingly skeptical that the deadline can be met.
While Senator Olympia Snowe has not shifted her position that a “trigger” must be associated with any potential public option, other key moderates appear to be softening. Senator Ben Nelson and others have expressed openness to an approach that would allow states the ability to opt out of a federally-run public plan. While there are not yet 60 votes for the opt-out approach, the middle ground of the conversation does appear to have shifted meaningfully to the left, with a federally backed public plan more likely than before. Use of Medicare rates by the public plan(s) continues to be highly unlikely in the Senate, or in the final bill.
Major Provisions
Following is an overview of the provisions in each of the major bills that passed out of Committee earlier this year. While the merged bills could look quite different, it is useful to see varying provisions being considered as the next phase of the debate unfolds.
Senate Finance
• Cost projected to be $856 billion over 10 years
• Creates health care affordability tax credits to help low and middle income
families purchase insurance in the private market
• Provides tax credits for small businesses to help them offer insurance to their
employees
• Allows people who like the coverage they have today the choice to keep it
• Reforms the insurance market to end limits on pre‐existing conditions and health status
• Eliminates yearly and lifetime limits on coverage
• Creates web‐based insurance exchanges that would standardize health plan
premiums and coverage information to make purchasing insurance easier
• Gives consumers the choice of non‐profit, consumer owned and oriented plans
(CO‐OP)
• Standardizes Medicaid coverage for everyone under 133 percent of the federal poverty level
• Requires adoption of standardized electronic administrative transactions to drive efficiency, reduce errors and lower costs
Senate Health, Education, Labor, & Pensions (HELP)
• State health insurance exchanges
• Government-run, public health insurance option to compete with private insurers to drive costs down
• Individual insurance mandate, with some exceptions for those who cannot afford coverage
• Employers with 25 or fewer employers also exempt from penalties
• Prohibiting insurers from denying coverage based on their health status
• Promoting quality through financial incentives for providers
• Coverage of preventive health services
• Extending coverage for dependent adults until age 26
• No lifetime or annual limits on individual or group health insurance policies
House Tri-Committee (Committees on Energy and Commerce, Ways and Means, and Education and Labor)
• Creation of a public insurance option
• Expanding access to health insurance
• Standardized benefits packages
• Provisions to end premium increases or coverage denials for "pre-existing" conditions
• Eliminating co-pays for preventive care
• "Affordability credits" to make premiums affordable
• Caps on out-of-pocket expenses
• Employer mandate- pay or play
• Guaranteed catastrophic coverage
Senate Finance Comes Out Strong on Administrative Simplification
All of the major healthcare reform bills include provisions that support healthcare administrative simplification, but the Senate Finance language remains by far the strongest. Specific provisions include:
• Timeline for accelerating existing HIPAA transactions
• Adds electronic funds transfer (EFT) as a required transaction
• Single set of operating rules for eligibility verification, claims status, claims remittance/payment, and EFT developed by a qualified non-profit entity, reviewed by NCVHS
• Rule to create unique health plan identifiers
• Requirement that health plans file a certification statement by Dec. 2013 that their data and information systems comply with the most current published standards for four transactions: eligibility verification, claims status, claims remittance/payment and EFT
• Requirement that by2014, no Medicare payment under Part A or Part B be made other than by EFT or an electronic remittance
Emdeon Supports Sensible Policies, Practical Solutions
Emdeon supports and promotes sensible public polices and practical solutions that make healthcare efficient. Our goal has been to help reframe the healthcare reform debate and focus on actions we can take today to take costs out of the system. Key areas like administrative simplification, program integrity/fraud and abuse, third party liability cost avoidance and public beneficiary management offer billions in potential annual savings.
The U.S. Healthcare Efficiency Index™, launched by Emdeon in 2008, identified $300 billion in savings over 10 years from automating the most basic healthcare administrative transactions. Emdeon has worked to raise awareness of these potential savings that can free up dollars to pay for delivery of care or offset costs of longer term reforms.
Read More >>
Congress begins task of merging five health reform bills into one
Member Management...moving efficiencies upstream in the healthcare cycle
by Sanju Pratap, Director of Payer Product Management at Emdeon
Healthcare is experiencing a retail-style transformation. Benefit, health and consumer oriented information are converging and being delivered at the point of care. Because of this, the point of healthcare service has evolved into a very teachable and effective moment- shaping behaviors and influencing outcomes... all of which directly contribute to downstream administrative and medical cost savings for payers.
In a market where efficiencies equate to increases in the bottom line, payers continuously look for additional solutions where they can do more with minimal resources. Emdeon has recently launched a Member Management product category - a suite of solutions designed to greatly reduce downstream administrative and medical costs by leveraging Emdeon’s eligibility-driven solutions and provider reach, payers’ benefit information and the provider workflow to create healthcare efficiencies upstream in the process.
Imagine using one silver bullet, your members’ eligibility & benefit data set, to address multiple market challenges upstream, at the point of service. That’s what payers can do with Member Management! Here are just a few of the key features and benefits:
Eligibility, authorizations, claim status and other related real-time inquiries are often viewed as just another communication requirement for interaction with providers. But by leveraging that information and workflow to enable real-time transactions, payers can use those transactions to also address the evolving pre-care administrative and medical information needs.
• Address multiple challenges with minimal and streamlined development & operational investment
• Improve member care management
• Enhance provider, member and employer group relations by enabling transparency, self service and a reduction in claim denials
• Comply with growing federal & state regulatory compliance – ie: HIPAA, CORE and State regulations
• Increase EDI & auto-adjudication rates
• Reduce waste & cost via proactive coordination of benefits and pre-adjudication services
Emdeon has helped payers ranging in size from 1,000 to several million members leverage Emdeon eligibility-based solutions to achieve HIPAA compliance, improve self-service via increased EDI transactions and web based portals, and increase auto-adjudication rates. These same payers are beginning to leverage existing solutions and operational processes to provide care management, transparency, coordination of benefit solutions and achieve compliance for the growing regulatory requirements.
Emdeon Member Management is a comprehensive approach fueled by the convergence of core healthcare transactions, benefit information management, constituent engagement and care coordination to address as many healthcare challenges as possible upstream in the process by leveraging existing provider, member and payer workflows.
As the marketplace evolves, consumers will be empowered with information to make better decisions regarding how they use and pay for healthcare services. Providers will use clinical data to deliver evidence based care and new tools to effectively manage their business. Payers will use existing proven solutions to support constituent performance-driven solutions to support a healthy population.
To be competitive in such a transformed marketplace, payers will need to remain competitive, achieve more with less, and realize the vision of a healthy population via synergistic solutions.
Emdeon is leveraging existing applications and workflows to address the rising market challenges upstream in the process…thereby greatly reducing downstream administrative & medical cost related challenges. For more information on Emdeon’s Member Management payer solutions, visit www.emdeon.com/membermanagement or contact spratap@emdeon.com.
Read More >>
Emdeon Partners with Susan G. Komen for the Cure® for Unprecedented Education & Awareness Campaigns
Thanks to Emdeon real-time technology and the real-life information of the Susan G. Komen for the Cure®, healthcare providers across the country will be able to print out practical, useful information for patients during appointments, potentially empowering thousands of people with deeper knowledge about how to detect and respond to risk factors, face challenges and get help.
Emdeon and Susan G. Komen for the Cure are partnering to revolutionize in-office, teachable moments by making breast health literature readily available to patients through their healthcare providers. The printable materials include topics such as “Breast Cancer Risk Factors”, “When You Discover A Lump”, and “Sexuality and Intimacy” in both English and Spanish formats. There is no limit on the number of times the providers may print the disease prevention and wellness materials.
These materials are currently available through the web-based software solution, Emdeon OfficeTM, a solution that enables healthcare providers to conduct everyday administrative transactions, including patient eligibility/benefits verification, claim submission, referrals, authorizations and pre-certifications for care. It is currently in use in professional offices representing nearly 100,000 healthcare professionals across the country.
In addition to exposing thousands of healthcare providers to readily accessible, print-quality downloads, Emdeon is engaging in another campaign to turn America’s mailboxes “pink” this October. During the month, Emdeon’s print and mail facilities will print outgoing consumer healthcare statement envelopes with a hot pink awareness message that reads, “Are you Inspired to Save a Life? Find out how at www.komen.org/inspire.” Since Emdeon sends millions of consumer statements each month, millions of people will be thinking pink this October.
For more information on this partnership, visit www.emdeon.com.
Read More >>
Encouraging Electronic Claims Submission Saves Money- up to $175,000 annually!
Did you know that most providers cite the top barrier to submitting electronic claims is simply a lack of information? Many times providers just need to be informed that a certain claim type can be accepted electronically, and sometimes it’s even as simple as informing the provider of the correct Payer ID. That’s where Emdeon Accelerated Growth Program for Claims comes in. By leveraging our extensive provider reach with our analysis of your organization’s electronic and paper claim volumes, Emdeon identifies EDI opportunities and customizes a growth program to increase electronic utilization among connected, submitting providers, and conversion to electronic for paper-only submitting providers. Payers who actively participated in a growth program in 2008 realized an average annual savings of nearly $175,000!*
Emdeon’s Accelerated Growth Program for Claims can impact your bottom line by increasing EDI transactions, improving auto-adjudication rates and moving your organization and the industry closer to paperless administration. Specific and measurable growth plans designed by Emdeon help payers capitalize on EDI opportunities to increase electronic adoption and utilization among providers. If your organization has an Emdeon Managed Gateway agreement, you may even be eligible to receive a complimentary growth program.
So take further advantage of your Emdeon partnership today– based on your provider claim submission trends, we’ll identify barriers and educate your providers through phone outreach campaigns, seminars and co-branded marketing campaigns. Contact your account manager, give us a call at 877.EMDEON.6 or email moreinfo@emdeon.com to get you on the road to saving more money today with Emdeon Accelerated Growth Program for Claims!
*Average annual savings of payers whose combined EDI/paper claim volume was 100,000-1,000,000 per month
Read More >>
Top 10 reasons Payers and Providers are experiencing more WOW with Emdeon Vision for Claims Management
Payers, providers and vendors all across the country are experiencing the WOW factor of Emdeon Vision for Claims Management. If you are a payer who processes claims through Emdeon, your customer service representatives can have access to this innovative, valuable reporting tool– don’t wait, enroll today. Here are 10 great reasons why you should enroll!
1. It's Fast!
Nearly 95% of all Emdeon Vision searches return search results in less than 5 seconds.
2. It's Easy!
Thanks to the simple user interface of Emdeon Vision, most users require NO training to use Emdeon Vision. For those users that do require training, Emdeon has created detailed training videos, a very thorough user guide, and online help available within Emdeon Vision.
3. It's included with your current service!
The ability to track claims in Emdeon Vision is complimentary for payers AND providers. No registration fee. No monthly fee. Consider it a free gift from us to you.
4. Experience a common view from one data source.
Emdeon Vision is used by Emdeon internal support, payers, vendors, and providers, all using data from a single source. With everyone using the same data, problem resolution is increased greatly.
5. Eliminate software or hardware maintenance.
Emdeon Vision is a web-based claim-tracking and reporting tool that can be used from any Internet-enabled computer. No new hardware or software is necessary.
6. Access historic claim data.
Emdeon Vision contains 15 months of claim data for all constituents (e.g. payer, provider and vendor). In this way, historical claim information may be reviewed for trends. All 15 months of historical claim data is available immediately upon registration. **
7. Eliminate software or hardware maintenance.
Emdeon Vision is a web-based claim-tracking and reporting tool that can be used from any Internet-enabled computer. No new hardware or software is necessary.
8. Improve provider relations.
Emdeon Vision can improve provider relations because providers can access their claim data easier and more quickly than through paper reports. This allows providers to “help themselves” rather than calling payers or vendors for claim information.
9. Reduce paper claim attachments.
With the introduction of Workers Compensation Attachments and Medical Claim Attachments in late 2009, Emdeon Vision will help payers and providers reduce the cumbersome and timely process of mailing paper attachments. The process is as simple as using Emdeon Vision to identify claims that require attachments, linking the attachment to the claim (a process much like attaching a document or picture to an email), and uploading the claim and attachment to the payer. As with everything in Vision, handling attachments is fast and easy.
10. Did we mention it is FREE?
Don’t wait– experience the WOW– learn more by visiting here or simply email us at moreinfo@emdeon.com to get started!
**Contingent upon length of time claim volume has been sent through Emdeon – if volume has been funneled through Emdeon for less than 15 months, availability is for the length of time volume has flowed through Emdeon.
Read More >>
Simplify the H1N1 vaccine administration claim processing with Emdeon
Emdeon is now enabling billing for the administration of the H1N1 vaccine on medical claims from pharmacies. We have the capability to make the process transparent to payers by integrating these claims into payers’ existing EDI medical claim feeds. Refer pharmacies to eRx Network, an Emdeon company at 1-866-erx-network and you’ll be on the road to greatly simplifying this complex process.
