You Decide-Back to the Drawing Board

May 3, 2018 Medical

As the CFO of Community Memorial Hospital, I have a major problem on my hands that could lead the hospital in a financial bid. Bill Jacobs, the Human Resource Director of Commercial Intertech (CI) which is the largest employer in the community, has signed a contract MegaPlan Health. MegaPlan is a known insurance company that gives hospitals a very hard time especially when it comes to discounts and fighting claims the hospitals make.

Since all of our employees and their families will be using MegaPlan Insurance and Community Memorial is not on their Preferred Provider Network (PPN), I need to figure out if we should work with or without MegaPlan. If so, I will have to decide to sign this contract that they sent over that includes a 35% discount from charges and service pre-authorization requirements or write a contract of my mine with all of our terms and conditions and see if they agree to it. Regardless of the decision I make, there will be major risk involved working with MegaPlan Insurance.

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After taking inconsideration everything scenario and thinking about everyone’s opinion (Chief of Staff, CEO, Business Office Manager and CNO), I have decided to take the CEO advise and make my own counterproposal and see what MegaPlan will say about it. I chose this option because I felt that MegaPlan is trying to get too much out of us especially when it comes to the 35% discount because I know from experience that the hospital loses money whenever the discount from charges exceeds 20%.

And the fact that MegaPlan wants us to pre-authorization requirements for services that need to be provider is just providing us with more work when we are already putting a lot of responsibility on our employees. According to healthcare. gov, pre-authorization requirements is when the health insurer or plan makes a decision whether a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary

My administrative team can barely reach the insurance companies when they really need them and to know give them the task to call and consult with the insurance company before the patient is able to receive treatment is only asking for trouble especially with the patients. I feel that I will have a better chance with MegaPlan signing my counterproposal than they have with us signing this existing contract due to the fact that I want to make sure that our patient get the best care and at the same time, the hospital will be able to survive and stay open for the community.

To start with my counterproposal, I will just basically change a few things within the contract that they sent over. I do agree with a discount for the employees and their families but the hospital have to also make some money in order to stay open, so I will change the discount to 17. 5% and this way we will meet in the middle. I will also change the pre-authorization requirements which will consist of getting approval for major surgeries and/or major treatments but everything else should be left up to the doctor’s decision.

I will also have to include that they tell us what exactly they will need in order to approve a claim so we will not have any issues in the future. I feel that my proposal will meet MegaPlan in the halfway and at the same time help our employees, the community and also MegaPlan Insurance. I will explain to MegaPlan how important this community needs this hospital and how much we need them and Community Memorial is always thinking of ways to help our community.

If we do not come to an understanding and agreement and become a part of their PPN, then some of our patients/employees may be forced to travel a long distance to another hospital and potentially see another doctor whether than their doctor that they have known all of their lives. Employees could start complaining to MegaPlan about the procedures that they may have to follow and MegaPlan could be dropped as their primary insurance company.

Even though MegaPlan Insurance is considered to be known for their cut-throat tactics, negotiating steep discounts and fighting every claim a hospital makes, they will have to understand that our community sticks together and at the end they have to figure out if they want to work with our entire community and not just be the primary insurance company. In conclusion, in today’s society, a supportive community can make a vital difference in the well-being of its members.

Accordingly, there is evidence that community-based health programs can play a strong role in improving the health status of a community’s citizens. So I am really confident that MegaPlan Insurance will definitely take this counterproposal inconsideration and I think eventually we will both come to an agreement but I have to stand up for my hospital, employees and community so I feel creating my own counterproposal is the best decision.

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