среда, 3 октября 2012 г.

Claim costs rising at PEIA - The Charleston Gazette (Charleston, WV)

fanny@wvgazette.com

The Public Employees Insurance Agency may have to startnegotiating fees with physicians, Director Tom Susman said Wednesdayin response to a significant increase in claims paid by PEIA.

From July 1 through April, PEIA-paid claims totaled $28.8million, a $5.8 million jump over the same period the prior year.

'We may have to look at physicians' contracts,' Susman said.

Last year, PEIA went to a 'facility-nonfacility' fee schedulethat attempted to reimburse costs incurred by doctors in hospitalsand by doctors with a higher overhead cost for their privateoffices.

But Susman said PEIA didn't accurately predict the cost of thechanges, and how they would change billings from physicians andother health-care providers after the changes. PEIA didn't domonthly tracking, he added.

'I don't think anyone costed it out enough to know what they weredoing.'

PEIA has five categories of fees, depending on the level ofservices. Susman said utilization has gone up to the highest code.

Staff believes some of the increased utilization resulted frompatients having to get periodic tests when they were taking newprescription drugs.

PEIA is the best payer of any large insurance group, the directorsaid. PEIA's fees were compared with Mountain State Blue Cross andBlue Shield's preferred provider organization, Carelink HealthPlans, and Health Care of the Upper Ohio Valley.

Claims paid to hospitals for in-patient services increased from$46 million to $48 million, and the outpatient claims went from $27million to $28 million during the same 10-month period.

Susman said PEIA currently has an evaluation committee that isreviewing bids received from private vendors to review bills fromphysicians and other providers to see if they are appropriate.

By the end of the fiscal year June 30, PEIA is projected to pay$47 million more for enrollees in its indemnity, or fee-for-service, plan. Susman said the estimated total is $299.18 million,compared with $253.77 million last fiscal year. 'It probably will be$50 million more by the time it's all said and done,' he said.

The pharmacy costs are projected to be $85 million, compared with$60 million the previous fiscal year.

Susman said 10,000 of the 200,000 people PEIA covers are comingback to the indemnity plan from managed-care programs, partlybecause Carelink offered a plan with less coverage.

The director is going to speak with representatives of the WestVirginia State Medical Association to see if the organization hasany suggestions. He said the association can help PEIA hold downprescription drug costs by telling the doctors to prescribe lower-cost drugs that will be just as effective as higher priced ones.

To contact staff writer Fanny Seiler, use e-mail or call 348-5198.