For Members: How Health Insurance Works

Many healthcare provider mergers—either due to their relatively small size or the structure of the transaction—do not trigger an HSR-filing requirement. Importantly, however, the antitrust agencies can still investigate—and challenge—a transaction that does not require an HSR filing. As with other mergers, Section 7 of the Clayton Act is the applicable antitrust statute for analyzing healthcare provider mergers.1Section 7 prohibits mergers and acquisitions “in any line of commerce . In any section of the country,” where “the effect of such acquisition may be substantially to lessen competition, or to tend to create a monopoly.” Although the U.S. Department of Justice (DOJ) and FTC both enforce Section 7, the FTC is responsible for the vast majority of merger investigations and enforcement actions involving healthcare providers. State attorneys general often join the FTC in its investigations and litigation.

For healthy enrollees, this is generally not a problem, as they don’t tend to have an extensive list of existing providers they want to keep using. But broad network PPOs tend to appeal to sick enrollees—despite the higher premiums—because they allow access to a wider range of specialists and medical facilities. Since health plans can no longer discriminate against sick enrollees by denying them coverage, many carriers have opted to limit their networks instead. The fourth step to building relationships with healthcare stakeholders is to collaborate and cooperate. This involves working together towards shared goals, values, and interests, while respecting diversity and autonomy. Collaboration and cooperation are essential for fostering rapport, mutual understanding, and collaboration with healthcare stakeholders.

UnitedHealthcare Interoperability APIs

If there are any questions, UnitedHealthcare Dental Benefit Providers will contact you within 5 business days. You’ll receive a provider welcome letter notifying you that credentialing and contracting is complete, along with the date you can begin seeing Indiana Hoosier Care Connect members as a network provider (your effective date). During the credentialing process, OptumHealth Physical Health will work with you to verify your qualifications, practice history, certifications and registration to practice in a health care field. This section covers the credentialing, contracting and enrollment process for facilities who are involved in testing, health care supplies and services. When you use Find a Doctor on our website or mobile app, we only show you in-network providers. Before you go to a doctor or hospital, it’s always a good idea to call and ask if they take your plan.

States, which along with CMS pay for Medicaid, are encouraging more and more managed Medicaid plans. The same private insurance companies will contract with the state to cover care for Medicaid patients and accept financial risk. Many patients have been added over the last several years to managed Medicaid plans via the Patient Protection and Affordable Care Act (ACA). Delighted customers tend to be loyal customers, and loyal customers tend to buy more products, make more referrals and switch providers less often. In other words, provide your customers with a service that is simple, digital and delightful, and they are more likely to remain your customers.

Provider Resources

Courts of Appeals for the Third, Sixth, Seventh, and Ninth Circuits, have ruled in favor of the FTC in its recent cases challenging provider mergers—specifically hospital and physician-group mergers—and in doing so these courts largely adopted the FTC’s analytical approach. Therefore, when counseling clients involved in a healthcare provider merger, you should be familiar with these cases and assume that the FTC—and courts—will take this approach in transactions that come before them, unless convinced otherwise. It’s clear that innovative programs to address SDOH are effective, but more work remains to be done to build on existing initiatives.

Millennials, particularly in developed markets, live on their smartphones. They use apps to arrange their daily lives, and they wear devices that monitor everything from the number of steps they customized software development for pharmaceutical companies take to how rapidly their heart is beating to how many hours they sleep. They own cars that track how safely they drive, and they use apps to control the climate and security of their homes.

Types of Marketplace plans

Providers often seek to merge to achieve various efficiencies, such as improving quality of care, achieving cost savings, and engaging in risk-based contracting and population health management. But convincing the FTC that efficiencies outweigh potential competitive harm is challenging. To do so, you must show that the efficiencies are merger-specific, meaning that they could not be achieved without the merger; are substantiated, meaning verifiable and not speculative; outweigh the competitive harm; and that the benefits of these efficiencies will be passed on to consumers.

Guidehouse also analyzed markets to see where performance on value may be lagging (based on cost, utilization, quality and patient satisfaction data). That’s an indication that a high-performing new entity could make a big impact. Leading healthcare institutions around the world are using our products and platform to innovate. Apps on iPhone and iPad are enhancing care delivery in the hospital, enabling new models of care at home, and transforming the way research is conducted. When your patients have their medical information organized into one view right on their iPhone, it can help them better understand their overall health and provide key elements of their medical history when visiting a new provider. Cigna HealthcareSM offers quality plan options, personalized support, and low costs.

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You can do this by serving on payer committees or by periodically meeting with medical leaders and using care management resources. Patient and referring physician satisfaction, or areas of clinical or program expertise, are excellent differentiators. Ask the payers for your quality and cost data, and if you are not at the top, find ways to move there. For example, if you see a lot of headache patients, know what percent of patients with benign headaches have imaging and what percent go to the emergency department, compared to others in the payer’s network. If you use the American Academy of Neurology (AAN)’s Headache Quality Measurement Set,10 or other measurement sets, show the results.

Acko General Insurance, an Indian insurtech that specializes in automotive insurance, excels at cutting through the complexity that has long bedeviled traditional insurance companies. Acko receives high marks from customers for providing products that are easy to understand, compare, purchase and use. By collecting, analyzing and comparing data from a broad customer base, auto insurers can make more informed decisions about underwriting, risk and claims, and can create rewards for customers with good automotive habits, such as regularly maintaining brakes and other critical systems. When connectivity strategies are well-designed and well-executed, both the customer and the insurer benefit. The customer pays lower premiums, and the insurer receives fewer accident claims.

How Health Insurance Works

To help ensure you are reimbursed quickly and patients get access to the care they need, we have developed a full range of training resources, including interactive self-paced courses and quick reference guides along with registration for instructor-led sessions. Topics include the digital solutions available on the UnitedHealthcare Provider Portal, plan and product overviews, clinical tools, state-specific training and much more. If a company’s employees pay higher out-of-pocket costs for a certain service, such as an X-ray or knee replacement surgery, the employer may try to get the insurer to negotiate better rates with the providers. In addition, the machine-readable data are publicly accessible, so entrepreneurs can build more user-friendly tools that allow consumers to estimate their out-of-pocket costs for medical care before they have a procedure done.

• From these customer ratings, we determined how much value a company created both overall and for individual elements.
• When your patients share Health app data with a provider, the data is encrypted in transit and at rest, and Apple cannot access or view any health data stored in connection with Health app data sharing with provider.
• That means if you go to a provider for non-emergency care who doesn’t take your health plan, you pay higher out-of-pocket costs.
• If we do not have a valid email address on file for you, we’ll mail or fax you the contract.
• The Healthcare Service resource typically describes services offered by a Pharmacy or Pharmacy Organization.
• In the event of a system response issue, restoration efforts will begin on the next business day.
• It can be helpful to show that a consultant or investment banker conducted or aided the search.

Proposals should be in writing, look professional, and present your position clearly, concisely, and with relevant data. Many believe that this effort will be wasted, as the payers will do what they do regardless of our reaching out to them. You may be wondering what power you really have to influence the suits in the fancy building. They were supported by Christy de Gooyer, practice director in the Financial Services practice in the Americas. Team members were Shilpi Gupta, Sonal Chawla, Arti Gupta, Sahiba Gambhir, Praneeth Iragavarapu, Vaibhav Sachdev, Shikhar Sachdeva, Rishabh Vasu, Chinoy Jain, Delphine Otzenberger, Saad Agoumi and Perrine Collet.

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That means if you go to a provider for non-emergency care who doesn’t take your health plan, you pay higher out-of-pocket costs. The main differences between them are cost and whether your health plan helps pay for care you get from out-of-network providers. Clearly you are in a stronger position to achieve your goals if you are in a large group.9 If you are in a solo or small group, implement a longer-term strategy that includes establishing relationships with key payer staff.