Practice Management

Ongoing changes in the physician office solutions market have important implications for both payer and provider organizations. Physician office solutions came into prominence in the1980s as medical practices turned to information technology to help manage the steady flow of patients and paper through the physician office. Current solutions continue to provide core practice management (PM) functionality, while also facilitating communication between the medical practice and payer organizations.

An asset sale by an insurance company or a health maintenance organization typically involves the transfer of a block of business and generally is accomplished by an "assumption" or "portfolio" reinsurance transaction (when risk is transferred from one insurer to another) covering part or all of the seller's existing business.

The relationship between providers and payers really hasn’t changed since HIPAA.

The Administrative Simplification section of HIPAA consists of a trioof regulations that address privacy, transactions and security. Implementationof the final Security Rule and its mandated security practices must be ineffect as of April 20, 2005, for most covered entities. Although the PrivacyRule requires the presence of "adequate safeguards" for ProtectedHealth Information (PHI), the Security Rule details more than 40 separateaudit points within the categories of technical, administrative and physicalsafeguards. While the Security regulation addresses what must be done, itdoes not provide a road map for how to do it.

MANAGED CARE executives may not keep an eye on Medicare, assuming it's an entirely different model and patient population. If recent trends continue, however, Medicare patients and Medicare rules could play an increasing role in a managed care patient mix.

You most likely are aware that in December 2003, Congress enacted the MMA (Medicare Modernization Act). Since the majority of Medicare's payments for drugs provided in physician's offices (Part B) are for cancer treatment, it's prudent to evaluate how MMA will affect specialty pharmacy reimbursement and provider revenues.

National Reports-Nine members have been appointed to the new Aetna Physician Advisory Committee, following the completion of an agreement between Aetna and physicians stemming from a national class-action lawsuit last year.

The pain associated with a degenerative hip condition had 37-year-old Gerald Amaral taking several prescription pain tablets on a daily basis to manage his discomfort. It's hard to believe that doctors say this former competitive mountain bike racer has the hip of a 70-year-old man.

What you don't know might hurt you

Special Report, Figure 3

Special Report, Figure 1

BCBSIL Chief Medical Officer Dr. Stanley Borg wants a financial model that supports PCPs

Evidence-based analytic engine

Faster pay and other incentives will drive provider adoption of autoadjudication

America's expanding waistline threatens to cripple a healthcare systemalready staggering under skyrocketing costs. Because of the magnitude ofthe problem, simple solutions are difficult to design and implement.

Automated applications detect fraud athat payers might not find with manual systems

Should you implement a healthcare reimbursement debit card? A few tips will help clear the path.

Patient-physician relationship remains key

A national health system recognized that its internal process was not improving

Regulatory and financial incentives drive the use of credit card technology in healthcare

Legislation expands reimbursement, but concerns about liability, eligibility and privacy might constrain its broad range expansion

An ASP-based system, coupled with overall proces improvements, can reduce denials, collection costs and bad debt

Can occupational medicine produce a profitable outcome?

State efforts to curb costs range from medical liability and tort reform to mandated benfits

Maximized use of resources and increased reliance on IT can pave the way for market advances

What do you do when you have exhausted all options for improving performance in an environment that is determined to protect the status quo? What do you do when your organization has reached the presumed limit of potential performance and has grown all too comfortable with its market lead?

Provider acceptance, administrative hassles, program design remain the important challenges

Quality initiatives and a group treatment approach might increase understanding and ease the cost burden of the disease

Early collaborative launches show promising results, but creating the infrastructure is easier said than done

Tools for each moment in care appeal to members who want to make smarter decisions