Healthcare providers urged to challenge insurers’ dictates

Hospitals and other healthcare providers need to take the fight to the health insurance industry at both the local and national level if they want to avoid getting the short end of the healthcare reform stick, according to Jeffrey Gold, vice president of managed care and special counsel for the Hospital Association of New York State. Gold spoke via speaker phone to a small group assembled to hear his presentation on the “fictions” of managed care at the Healthcare Financial Management Association's Annual National Institute in Seattle.

Gold apologized to the attendees for not being able to address them in person, saying he had to stay in New York to oversee a piece of state healthcare reform legislation in Albany that’s in limbo because of a change in leadership in the New York State Senate. In his more than hourlong presentation, Gold chided the group of about 30 healthcare executives for blindly accepting a number of managed-care dictates that have put hospitals and other providers at a financial disadvantage for a number of years. Among those, according to Gold, are an insurance-industry-run database that sets artificially low “usual and customary” fees for services; administrative denials for medically necessary services covered by insurance; and audits of claims that were fairly closed. “Providers must challenge the policies they believe are faulty immediately,” Gold said. “And not just tinker at the edges.”

Gold urged hospitals and other providers to approach national healthcare reform with the same zest and not just accept the insurance industry’s promise to improve underwriting practices. He said providers must demand that insurers address claims payment practices and re-investment in the healthcare system as part of a national reform plan.

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