Q: If a provider accepts a lower rate for a payment from an insurance company, the municipality will bear a larger portion of the expense, correct?
A: If a provider accepts a negotiated rate of payment and that payment from the insurer is made in an amount less than the State-approved early intervention rate for the service provided, the ISFA will process payments for the balance due the provider from the escrow account using municipal funds at State established rates for the EIP. Billing providers will receive the full EIP rate for delivered services. If the provider does not accept the negotiated rate, and the insurer subsequently denies the claim for reasons such as out of network provider, then the entire payment will be made from the escrow account.
We have established a policy to refuse the 'negotiated' rate of payment for home based early intervention services UNLESS it is equivalent to the established rates for the EIP. Most early intervention providers are not aware that standard commercial reimbursement rates have been established based on a Medicare standard that assumes that the visit is occurring in a clinic setting. Therefore, we are expecting that most of the 'negotiated rates' will be based on pre-existing clinic-based reimbursement schedules.
To date we have not been approached by ANY commercial insurance entity to NEGOTIATE a rate for home based early intervention services. Therefore, we are operating under the assumption that reimbursements will occur under the existing schedule (which actually does not even account for home based visits).
We encourage the NYS Early Intervention Program to cease using the misnomer 'NEGOTIATED RATE' unless there is evidence that negotiation has occurred.
The reason why this is important is because of what we posted several weeks ago - please reference the blog post at http://abctherapeutics.blogspot.com/2013/06/remember-what-was-in-2013-2014-nys.html
In summary, again, NYS had every intention of leaving reimbursements up to a negotiated decision between providers and insurers. The plan was that providers will accept this rate as PAYMENT IN FULL and WOULD NOT SEEK ADDITIONAL REIMBURSEMENT FROM THE FAMILY OR THE MUNICIPALITY. Please read the Governor's proposal.
Anyone who accepts the insurance company 'negotiated' rate will set themselves up for having to accept that rate if the Governor's proposal as previously advanced ever makes it into law. In the future, there will be no escrow, and that 'negotiated' rate will be 'PAYMENT IN FULL."
Most insurance reimbursements for clinic based therapy services are at approximately 70% of the early intervention home based rate. The home based rate is higher, as it should be, to account for travel and other costs associated with providing therapy outside of a clinical/office context.
Accepting 70% as a 'negotiated rate' today will leave the program in a state of absolute decimation if the Governor's proposals are ever made into law. There will be NO providers willing to provide home based services at that low rate and the system will collapse into a model where only clinic-based services are affordable to provide.
Do not expect that insurance companies will suddenly decide of their own volition to raise their reimbursement rates just because the State pulls out of the system. It WILL NOT HAPPEN and providers will receive less pay and leave the system and families will go without these services.
This is so clearly obvious and there is no doubt in my mind that lawmakers and administrators understand this dynamic precisely. Please read the Governor's proposals and develop an understanding of the impact of simply accepting this so-called 'negotiated rate.'
I call upon the Bureau of Early Intervention and the Governor's office to simply COME CLEAN regarding their intentions. If it is the intention to dismantle the program by driving reimbursements down to the point where there will be no more home based providers - then just say it. Being dishonest will hurt many families as they end up being in a reactive mode when therapists are not available. Being honest will allow other systems to step in and make up for what NYS is no longer able to afford, and will allow families to make decisions in a more proactive manner and within new service delivery models.
Although I would not expect it, the Governor could alternately provide some assurance that NY State will support a 'minimum rate' and not attempt another sneaky parachute jump out of fiscal responsibility for the program. That would leave the integrity of the home based model as it is, would allow providers the freedom to safely 'accept' whatever rates the insurance companies paid, and there would be assurance that the municipality would pick up the rest.
At this point I trust nothing. The concept of cost-sharing between the insurance companies and the municipality is reasonable and very fair from a policy perspective. Governor Cuomo tried to pull a fast one and bail out of responsibility altogether - and this should be enough evidence of how little he cares for this program on any level.