Tag Archives: Howard Kahn

Out-of-network claims in commercial insurance

Many health plans allow members to receive covered services from providers who are not part of the plan’s contracted network. However, a plan will often limit the amount it pays to a specific percentage of an amount called “usual, customary, and reasonable” (UCR). Historically, the UCR amounts have been determined by reference to commercially available schedules representing prevailing physician charges by types of service and geographic regions. Some plans have recently replaced the use of such schedules with Medicare’s resource-based relative value scale (RBRVS) schedule.

The differences in reimbursement levels between fee schedules based on Medicare’s RBRVS and benchmark data based on prevailing charges have led to some unexpected results for both members and physicians. These unexpected results still exist even if the change is designed to produce similar levels of aggregate reimbursement under both methods.

This issue is explored in more detail in this new Milliman white paper.

ACOs beyond Medicare

Physicians and hospitals are facing unprecedented pressure from healthcare purchasers to deliver higher-quality, more cost-effective care. This paper discusses how it will be increasingly difficult for individual providers to continue without joining a larger integrated system. For many of these emerging systems, a partnership with a health plan will be much more attractive than becoming an accountable care organization (ACO) serving Medicare fee-for-service (FFS) beneficiaries.