As such, calculating market shares is one tool you should use to assess the potential for FTC scrutiny in a provider merger. As a starting point, you should identify how the merging parties calculate market shares in the ordinary course of business. You should also try to determine whether the FTC could plausibly identify any narrower markets (e.g., an individual service line or a narrow geographic area) that would result in high shares. The FTC includes in the GAC hospital services market only inpatient services that both merging parties offer; it excludes services that only one of the merging parties offers.
For more than 125 years, Cigna Healthcare has been committed to building a trusted network of health care providers so we can connect our customers with truly personal care. Numerous states had stepped in with laws and regulations to address surprise balance billing, opting for various provisions that hold the patient harmless in situations like this. But these laws were only applicable to state-regulated plans in that particular state, and they didn’t apply to self-insured health plans, which are regulated at the federal level instead. You will pay lower copays and coinsurance when you get your care from an in-network provider, as compared to when you get your care from an out-of-network provider, and your maximum out-of-pocket costs will be capped at a lower level.
Canadian insurer Desjardins has joined with Roost, a Silicon Valley insurtech and maker of telematic devices. Insurers promise their policyholders peace of mind by using data from the devices to help detect and prevent leaks, fires, outages, intrusions and other events that can lead to damages, losses and claims. Insurers have had less experience—and less success—with offerings tied to so-called smart-home connected devices.
- Data that represents medication products to be or has been dispensed for a patient.
- Insurers can use the data collected by these devices to develop products and services that are geared to their customers’ individual needs.
- Many insurers have not seen a significant rise in their Net Promoter Score® (a key indicator of customer loyalty) since Bain’s first global survey in 2014.
- One community’s major challenge could be that aging housing stock has not been maintained (ie, housing quality) or that a recent boom in employment has led to increased demand and costs (ie, housing affordability) with a limited supply of available units (ie, housing availability).
- Sharing health data with a provider also uses this same OAuth 2.0 mechanism to establish a secure connection to your EHR.
- Finding common ground with the payer is also important as this will help set the stage for a productive conversation.
You should also note that the safety zone does not apply to non-GAC hospitals, such as specialty hospitals or to other types of providers. While the efficiencies defense has not rescued an otherwise anticompetitive provider merger in court, merging providers have successfully convinced the FTC to close merger investigations at least in part on this basis. Therefore, there are steps you can take to increase your chances of successfully making an efficiencies defense. First, although it can be costly, you should consider whether to hire an efficiencies consultant or expert to help assess and substantiate any claimed efficiencies, at least in transactions that are likely to raise competitive concerns. Second, although it is not an element of the efficiencies defense, the merging parties’ efficiencies claims will be more credible if they document that efficiencies were a driving force for doing the transactions, as opposed to a last-minute justification for the FTC to approve the deal. Finally, efficiency claims may be more convincing when the target firm is under financial duress, quality may be compromised absent the transaction, and the parties combine their efficiencies claims with a failing- or flailing-firm defense, as described below.
Dental Care, Covered
The following are additional ways to identify and mitigate antitrust risk if a provider merger is likely to be investigated or is under agency review. For organizations that think establishing a closer payer-provider relationship would be worthwhile but aren’t sure how to get started, Nugent said a key initial task is to use analytics. HFMA empowers healthcare financial professionals with the tools and resources they need to overcome today’s toughest challenges.
Existing contracted groups/facilities – If you’re joining an existing group that already has a contract with UnitedHealthcare Community Vision Network / March Vision Network, you will be added to the group contract once credentialing is approved. Once your signed contract is received, they’ll countersign the contract and send you a copy, along with the date you can begin seeing Indiana Hoosier Care Connect members as a UnitedHealthcare Community Vision Network / March Vision Network provider (your effective date). Contracting is a separate process from credentialing – we’ll start the contracting process with you while you’re working through credentialing. Once UnitedHealthcare Dental Provider Benefits receives your request, the Network Contractor will send you a dental credentialing checklist. If you work in this specialty area, you’ll work with UnitedHealthcare Dental Benefit Providers for credentialing, contracting and enrollment. If there are any questions about your credentialing application, OptumHealth Physical Health will contact the you via email to address them.
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Designing interventions to address SDOH can be challenging because every person and every community is different. People’s needs change over time, and the availability of community resources varies by zip code. As a result, there is no one-size-fits-all approach to addressing social barriers (Box 2).
Though dated, antitrust counsel still use the Health Statements because they provide guidance on the agencies’ enforcement policies in healthcare. Of relevance to provider mergers, “Statement 1” provides a safety zone from antitrust enforcement for certain hospital mergers. Statement 1 states that hospital mergers that fall under the safety zone will not be challenged absent extraordinary circumstances. This safety zone applies to mergers of two general acute care hospitals where one of the hospitals has had an average of fewer than 100 licensed beds over the three most recent years and an average daily inpatient census of fewer than 40 patients over the three most recent years. The exemption does not apply if that hospital is less than five years old, however.
Buying Medical Coverage On Your Own?
Understanding whether the merging providers are two close competitors with few or no attractive alternatives for insurers and patients to turn to will illuminate whether the transaction is likely to raise competitive concerns. Moreover, your provider client should speak with its commercial insurance partners about the transaction before it is announced—or at least before the FTC contacts the insurer—to explain the benefits of the transaction and assess whether they have any concerns about the merger. Finally, for transactions raising meaningful risk of antitrust scrutiny, you should consider hiring an economic consultant specializing in healthcare to analyze the discharge data and other aspects of the transaction. The ultimate antitrust question in any merger is what effect, if any, it will have on competition. In a provider merger, the primary question is whether the transaction is likely to result in higher prices or a diminished incentive to maintain or improve quality of care. In particular, the FTC will evaluate whether the combination is likely to give the merged providers enhanced bargaining leverage in negotiations with insurers.
Research has shown that these SDOH factors have a huge impact on people’s health outcomes. Some have estimated that medical care alone (eg, doctor’s visits, medications, treatment plans) addresses only about 20% of health outcomes. We encourage health care professionals to use with our online systems and resources.
Chiropractors Added to Providers Not Required to Connect to NC HealthConnex
The more leverage a provider has, the more likely that it can negotiate for higher rates; conversely, the more leverage the insurer has, the more likely that it can resist rate increases. The FTC is concerned about provider mergers that substantially lessen competition because that may provide the merged firm with enhanced bargaining leverage and enable it to extract higher prices. On the other hand, if merged providers’ customized software development for pharmaceutical companies bargaining leverage with insurers would not substantially change after the transaction because, for example, there would be adequate alternatives to which the insurer could turn, then the transaction is unlikely to raise competitive concerns. A health insurance provider network is a network of medical professionals and facilities that have agreed to accept a discounted rate for members of a particular health plan.
They see connected devices and services playing an important role in these ecosystems. At the same time, customers in many markets are also increasingly open to buying insurance from nontraditional sources, especially big tech companies. In terms of qualitative evidence, the FTC evaluates testimony and documents from the merging providers and area insurers, rival hospitals, and employers about several factors in defining the geographic market. In this framework, the relative bargaining leverage of the provider and the insurer largely determines the outcome of that price negotiation.
Investing in prevention is key to healthier people, healthier communities, and lower healthcare costs. Knowing this, health insurance providers and other healthcare professionals are increasingly investing in innovative solutions that address social barriers to health and wellness, also referred to as social determinants of health (SDOH). Reimbursement for care is usually paid by insurance companies, state government, or federal government intermediaries.