The Payer Perspective

My current role is the manager of a claims department and my educational background is in the area of medicals records. In my twenty-five years of experience in health care, I've worked on both the provider and payer sides. Currently being on the payer side, we monitor for many regulatory changes for example claim submission requirements, receipt of claims via paper or in a compliant electronic format, and monitoring for annual changes with procedural or diagnosis coding changes. ICD-10 is on the horizon for implementation in 2013 which will also take a great deal of effort from the payer community. We recently implemented mental health parity meaning the we are required to pay for mental health services that same as any other medical care. Our membership includes commercial, self-funded and governmental programs.

With the enactment of Health Care Reform on March 23, 2010, the initial impact will be on payers to modify the benefit structure to ensure compliance six months after enactment, or as early as plan year renewals after September 23, 2010. The immediate and visible changes for 2010include: no pre-existing limits on children up to age 19, no maximum lifetime benefits on essential benefits, no annual limits on essential benefits, coverage and no cost-sharing on routine preventive services and dependent coverage up to age 26. Other reform changes are scheduled for 2014, 2019 and potentially later. There will certainly be challenges as we modify our processes to comply with the required changes, but our focus will remain on being compliant and providing quality services to our membership population.

In some situatons, a self-funded group (meaning they fund 100% of the medical costs incurred by their employees) may elect if they will comply with changes in mandated benefits. Therefore, the focus of my comments will be limited to coverage offered to the commercial membership (meaning that the health plan is paying for care from the premiums collected).

The reform supports the removal of annual benefit limits, but to implement, we do need the clarification on the definition of essential benefits. Legislation changes effective January 1 2010 for Wisconsin residents already accommodates for the ability to cover dependents up to age 26. The reform split the removal of pre-existing considitions requiring that it is removed for children this year and adults at a later date and in conjunction with health exchanges.

In our current commercial benefit structure, our members do have coverage available to them allowing them to receive specific preventive services from participating network providers at 100% coverage. Our benefit is follows the adult and childe preventive care guidelines which allows for consistent benefit application. The primary outpatient care that can be received and paid at 100% on the initial services is: an annual physical and/or gynecological exam, mammogram, pap smear, lab for fasting blood sugar, lipid panel, prostate specific antigen, routine childhood and adult immunizations and a screening colonoscopy after age 50 or earlier if family history. Our quality department staff monitors the care received and send reminders as appropriate to encourage that member's schedule this care.

In our interpretation, we and our membership should be in a ready postion in the implementation or enactment of the reform.