Archive for October 17th, 2011

Government Mandated Fee Schedule: Does History Repeat Itself?

Monday, October 17th, 2011

Here’s a modest suggestion re an alternative fee schedule methodology that deserves careful consideration by legislators and regulators alike –

From the medical fee schedule section of the Code of Hammurabi (1730 BCE):

215 If a physician make a large incision with an operating knife and cure it, or if he open a tumor (over the eye) with an operating knife, and saves the eye, he shall receive ten shekels in money.

216. If the patient be a freed man, he receives five shekels.

217. If he be the slave of some one, his owner shall give the physician two shekels.

218. If a physician make a large incision with the operating knife, and kill him, or open a tumor with the operating knife, and cut out the eye, his hands shall be cut off.

219. If a physician make a large incision in the slave of a freed man, and kill him, he shall replace the slave with another slave.

220. If he had opened a tumor with the operating knife, and put out his eye, he shall pay half his value.

221. If a physician heal the broken bone or diseased soft part of a man, the patient shall pay the physician five shekels in money.

222. If he were a freed man he shall pay three shekels.

223. If he were a slave his owner shall pay the physician two shekels.

224. If a veterinary surgeon perform a serious operation on an ass or an ox, and cure it, the owner shall pay the surgeon one-sixth of a shekel as a fee.

225. If he perform a serious operation on an ass or ox, and kill it, he shall pay the owner one-fourth of its value.

Gary Anderburg of Broadspire was kind enough to forward this to my attention; he included the veterinary section just for comparison purposes. Gary says, and I agree, that we should give serious thought to reinstituting this, and go back to shekels.

That said, I’m wondering if Medata, Coventry, Mitchell, Stratacare, MCMC, and ACS/CompIQ can get this programmed…

Posted by Joe Paduda at 7:33 AM | Link to this post | Comments (3)

HB 2697

Monday, October 17th, 2011

Out-of-network ASC charges subject to U&C payment under HB 2697 –

Editor’s Note: If passed, this could have a profound effect on Cost Plus groups in Texas. Are PPO negotiated rates higher than U&C rates? The answer is YES in most cases. If that is true, then why would anyone want to pay more?

Texas May Shift Convict’s Care – New Provider Network Contemplated

Monday, October 17th, 2011

                Convict Health Care


Proposed: Texas Medical Reinsurance System

Monday, October 17th, 2011

               A Bill introduced in the Texas House, HB 2165 establishes the Texas Medical Reinsurance System that will assist self-funded employer sponsored health plans in the purchase of competitive stop loss cover.

Health insurance stop loss cover is essentially a twelve month contract, with the right of the carrier to re-evaluate the risk upon renewal. Large potential claims identified as possible risks to be paid in the succeeding Plan year may be passed on to the Plan Sponsor in whole or in part, thereby limiting competition for the Plan Sponsor seeking competitive stop loss cover.

The Texas Medical Reinsurance System would provide protection in such events by offering aggregate stop loss cover to insure claims exceeding a specified dollar amount or a percentage of expected claims. A two year extention of coverage for two succeeding policy years plus portability would move to any new carrier should one replace the previous carrier.

See details here –

Section 1676.004, Repricing Schedule, (B) (1) & (2) provides for the basis of medical care reimbursement. Physicians to receive 110% RBRVS and facilities (hospitals, out-patient surgical centers, etc) to receive 140% RBRVS.

Editor’s Note: While the concept is a good one, and will fix an inherent problem associated with a self-funded employee welfare plan, we think the private sector is better equiped to facilitate the scheme rather than a single payer reinsurance system as proposed by HB 2165.