Why Aren’t Providers Being Paid Fast, Accurately, and Fairly?

2 min

Payment disputes between insurers and providers are nothing new. Even with their secret, self-serving network contract arrangements, these relationships have been perpetually uneasy.

While insurers have billions of dollars in claims adjudication technology and staffing that should make processing and paying claims more rapid and accurate, they have always delayed payments to providers, sometimes as long as nine months or more, because every dollar they “float” for an extra day is to their shareholders’ advantage. But lately, this longstanding practice of delaying payment has worsened.

Kaiser Health News reports that the country’s two largest insurers are behind on billions of dollars in payments owed to hospitals and doctors nationwide. As of June 30, 2019, Anthem Blue Cross had not paid 43% of its medical bills. That figure has risen to 53% since the pandemic, and yet profits were $3.5 billion for the first half of 2021.

So why is this escalating? Some insurers point to the chaos driven by COVID-19. Others have introduced new and opaque reimbursement rules under the guise of cost-saving measures. Whatever the purported reason, these practices are indefensible in the face of ample resources and healthy bottom lines. More importantly, they are negatively impacting patients and providers in unprecedented ways.

According to VCU Health, an academic medical center affiliated with Virginia Commonwealth University, 52% of outstanding claims are more than 90 days old, despite a Virginia law that requires insurers to pay claims within 40 days. This delay has created “an unmanageable disruption” that threatens to undermine the financial footing of their teaching hospital in Richmond, Virginia.

Providers aren’t the only ones affected by egregious payment practices. Patients are reporting significantly more claim denials and prior-authorization hurdles than usual. The American Hospital Association asserts that insurer demands that go against the provider’s advice appear to be motivated by profit. Patients who receive recommended and routine treatments are now receiving astronomical bills when such services are deemed “experimental” and “not medically necessary.”

Doctors and hospitals appreciate knowing in advance how much they will be paid, and then getting paid quickly and accurately. Ethical health plan administrators who follow this practice, while still applying rigorous pre-payment scrutiny for billing fraud, waste, and abuse, are acting in the best interest of their clients and their clients’ members.

Welcome, Tim!

2 min

When your mission is to deliver a lower cost, better health plan that’s unsurpassed in the industry, you need a Chief Executive Officer who not only shares that mission, but has the experience and entrepreneurial mindset to shake things up and blaze a unique path.

Tim OBrienWe are therefore delighted to introduce our new CEO, Tim O’Brien, whose 25+ years of health and insurance experience will help Vitori Health continue transforming the industry.

Throughout his career, Tim has created innovative solutions that coordinate care, lower costs, and improve outcomes. He has also developed and implemented growth strategies and managed large scale operations, sales, and IT functions for global healthcare and IT organizations.

According to Tim, “The timing couldn’t be better for Vitori Health. We are uniquely positioned to deliver a comprehensive health plan that significantly lowers costs while providing members far better support than conventional health plans today. The Vitori solution has been incubated, tested, and optimized over several years with thousands of plan members. This gives us the confidence to deliver on our promise. It is a pleasure to work with such an experienced team and we are pleased to see incredibly strong market interest.”

Tim previously served as the Officer in charge of care delivery and strategic investments for Blue Cross and Blue Shield of Kansas City (BlueKC). He has developed national primary care solutions, multi-specialty surgery centers, and pioneered virtual behavioral health solutions. Tim served as the Chief Operating Officer of an integrated health care and capital management firm and delivered healthcare solutions in the UK, Middle East, and Latin America.

Tim is based in Kansas City where he will expand and strengthen our regional presence while leading the Vitori Health team to continue to serve clients nationwide. Please join us in welcoming Tim to the organization as we gear up for unprecedented growth and success.

UN-MINCED | Stardate 20210101

4 min

New Year’s Entry

There must be some kind of way outta here
Said the joker to the thief
There’s too much confusion
I can’t get no relief

       Bob Dylan (Jimi Hendrix cover preferred)

It’s 2021 and we find ourselves more than a fifth of the way into the 21st century. Let that sink in. That’s about 12,000 years or so into the Holocene or Human Era, the beginning of which roughly marks the point when we moved from casting about for food to planned agriculture and fixed settlements, working up to the most recent four decades during which we have made a stunningly atrocious mess of US health care, particularly at the ever more costly expense of employers and the sapiens they hire and provide benefits (we’ll get into the inanity and vexedness of this toxic quicksand in future posts).

Back To the Future

It’s the early 90’s and I’m sitting in the wood-paneled offices of Rick Wagoner, then CFO and eventually CEO of General Motors, one of the largest companies in the world at the time. I was part of an academic delegation from the University of Michigan* that had been summoned to Wagoner’s chambers to address a problem: GM was spending over $1,000 dollars on health care for every vehicle it produced. To hear it from Wagoner, they were “…spending more on medical stuff than we are on steel.” This didn’t sit well. In fact, GM, Ford, and Chrysler would be decried by Goldman Sachs as “HMO’s on wheels.” Worse yet, the multiyear cost trend was steeper than any of GM’s other expenses. By a lot. Keep in mind, this was at a time when Pacific Rim automakers were giving US auto companies fits. Wagoner was apoplectic and wanted answers. After polling my elder colleagues and wading through a litany of academic responses, he fixed his eyes on me and said, “Well young man, what do you think we need to do?” I glanced at my colleagues, who looked like someone had just placed a puppy at the steering wheel of one of GM’s cars. Looking back at Wagoner I said, “It seems like you need to get out of the health care business.” The room went silent and after what seemed like an eternity, Wagoner cocked his head, wryly smiled, and said, “That’s the best damn answer I’ve heard so far.”

The Firemen Are the Arsonists

I don’t juxtapose these time span bookends because my waning cerebral neurons can only recall the very recent or the distant past, although I’m sure some of that is happening. Nor do I mention this as a reminder that I was then, as now, a bit of a cheeky smart aleck. Anyone who has paid attention to the “health care“-becomes-“health business” saga of the US system and employer-sponsored health plans as a professional, or simply consumed the news once a week, knows all too well that only one thing has changed over this long stint: it’s gotten much worse. We have medical marvels of innovation wrapped in a stone knives and bear skins fragmented, inefficient, and ungodly expensive delivery system. In the employer health benefits arena, we have a plutocracy (kleptocracy is probably more fitting) of entrenched medical-pharma-insurance monopolies with vested interests who gorge themselves at the legacy economics trough. The collusion is deep and broad, functioning like a big time wrestling stage play with these actors pretending to beat up one another, feigning public good and allegiance to employers, while back-patting in the locker room as plan members and patients are ground in the gears of their collective machine and shareholders cheer from ringside seats. These oligarchs and cartels are plump and pleased and aren’t going to simply disintermediate themselves. As icing on this inedible cake, we have a longstanding disquieting co-dependency between employers and traditional brokers (who work as middlemen sales agents for the big insurance monopolies in a throwback to 1980’s manufacturer reps with their “books of business”) that anneals the status quo and retards change. One can almost hear this cabal of entitled industry stakeholders laughing all the way to the bank. But, it’s not funny, not funny at all, and we need to do something about this bullying and racketeering.

Patience (and Patients) Wearing Thin

As we go forward, we’ll examine the pathology of this juggernaut that continues to crush employer profits and employee disposable income and look at real opportunities for escape to a better place. And while it’s academically stimulating to think about large scale system solutions and health care as a basic utility in a first-world country, we are focused on less quixotic employer-sponsored health care solutions and take a SEALS approach; there are endless rescue missions to be run and we need to get ‘er done.

The name Vitori is a linguistic derivative of victory. It’s high time employers and their people moved from victim to victor. So, belt in buckaroos, there is a road less traveled that makes all the difference.

Let’s get after it.

* This is woefully ironic because, at the very same time, the University of Michigan Medical Center was becoming a “health system,” gobbling up physician practices and other hospitals like a black hole on amphetamines and raising prices with every expansion mouthful it could chomp. Sounds a lot like today’s sprawling health systems that are blocking out the sun as they buy their way across vast geographies, claiming bogus integrated efficiencies while continuously jacking up the cost of care and suffocating competition. Justice Department and FTC are you comatose???

A thought leader to the thought leaders, Neil Quinn has a very particular set of skills acquired over a very long career that make him a nightmare for the status quo.

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