Category Archives: Integration

The UPMC – Highmark Dispute: The Beginning of the End of Medical Practices Using Hospitals’ Managed Care Contract Rates?

Recent trends across the country have health systems buying out private physician practices and reclassifying them as hospital-outpatient departments.  There are a number of motivations behind these transactions, the greatest being managed care contracting.  Typically, the physician practice will reassign its Medicare NPI Number to the Hospital and the Hospital will then bill exclusively under that NPI number.  The Hospital will also submit claims to the third party payor and receive payments based on the hospital’s negotiated contract rates and fee schedule.

Critics, including a number of insurers, have claimed that this practice allows the hospital to bill higher rates for the same service at the same location.  For this reason, on February 26, 2014, Highmark, a  Blue Cross Blue Shield company based in Pittsburgh, stated that it would stop reimbursing health systems at higher hospital-outpatient rates for cancer treatment performed in physician offices.  Highmark explained that this move would save patients’ money by reducing out-of-pocket costs for deductibles and co-insurance. Continue reading

Ohio Delays ICDS Program Launch Date

Last week, Ohio Medicaid Director John McCarthy announced that the launch date for voluntary enrollment in MyCare Ohio (fka as Ohio’s Integrated Care Delivery System) will be delayed until March 1, 2014.  The announcement was made during Director McCarthy’s recent testimony before the Joint Legislative Commission for Unified Long Term Care Services and Supports. Continue reading

Activities Unrelated to the Medicare Shared Savings Program and Tax Exemption for ACOs

Last November, the IRS released Revenue Ruling 201145025 denying an application for tax-exempt status of an entity owned by a tax-exempt hospital (the “Entity”).  The Entity primarily contracted with commercial payors to provide hospital services and physician services.  The Entity’s activities are comparable to the activities an Accountable Care Organization (ACO) may conduct unrelated to the Medicare Shared Savings Program (the “Savings Program”), such as shared savings programs with commercial payors.  The Revenue Ruling, therefore, provides additional guidance regarding the IRS’ concerns relating to the activities of ACOs that are unrelated to the Savings Program. Continue reading

Benesch Sponsors ACG NY – 4th Annual Health Care Conference

Benesch had the opportunity to sponsor the ACG NY 4th Annual Health Care Conference on January 25th, 2011 at the Metropolitan Club in New York City. The conference was a great success with attendees from the private equity, lending, investment and service provider communities. We want to thank all those who attended the conference. It was a great event.

More importantly, we wanted to thank the panelists who put on a great presentation. The panel presentation provided significant insight into the coming challenges and unknowns for the hospital sector in 2012. The discussion of policy initiatives that are pushing toward more integration and the assumption of risk by providers was enlightening. Continue reading