Since the beginning of managed care, Americans have feared receiving care from doctors or hospitals who are “out-of-network” because that often means sky-high prices and more out-of-pocket costs. But what happens when the opposite is true – when the “in-network” rate is unfair and higher than the “out-of-network” rate for the same exact service? How does that […]

The SIIA 43rd Annual National Conference was a great experience that drove great discussion around industry trends regarding new compliance regulations, particularly with 2023 enforcement deadlines approaching for the Consolidated Appropriations Act (CAA) and Transparency in Coverage (TiC) rule. The enforcement deadline for the web-based price transparency tool could prove to have an interesting effect […]

Introduction On June 21, 2022, the U.S. Supreme Court published its decision in Marietta Memorial Hospital, et al. v. DaVita, et al. In this decision, the Supreme Court ruled that self-funded health plans have the authority under the Medicare Secondary Payer Act to carve out dialysis benefits and set rates for such benefits at appropriate levels […]

Renalogic releases industry report featuring trends to combat massive claims PHOENIX, AZ and CHICAGO, IL —November 8, 2021 – Renalogic, the industry leader in dialysis risk management and cost containment sponsored market research with the country’s top benefits consultants to gauge frontline perspective on the evolution of reference-based pricing (RBP) programs. With survey respondents expecting […]

Today, cost containment comes in many forms. In the ongoing debate about “reference based pricing” (RPB), it turns out RBP has evolved and diversified into specialized cost containment tools that have overcome some of the industry’s early barriers to success. For example, many health plans are using cost containment only in highest claims cost cohorts […]

Below is an example of a common conversation being had with brokers several times a week. Since the Circuit Court Rulings late last year allowed Large Dialysis Organizations (LDO’s) to weaponize the Medicare as Secondary Payer Act (MSP), many plans are “hedging their bets” and “hoping for the best” as plans that are using a […]

BACKGROUND Dialysis claims costs are a significant health plan financial exposure, and a profit center for DaVita and Fresenius that control almost 90% of all outpatient dialysis facilities. Therefore, dialysis cost containment is a primary focus of providers’ litigation against plans, most recently by DaVita under the Medicare Secondary Payer Act (MSP). The MSP coordinates […]