Wisconsin Long Term Care is examining deficiencies in a claims reimbursement cycle where the provider submits the bill to a large public funded insurance plan for payment. The claims reimbursement cycle is being implicated in the lack of participating providers. Providers have described personal experience of non-payment as a primary reason for not contracting with fund administrators authorized to facilitate delivery.
Wisconsin service providers explain the larger hospital and health care centers try to shift claims reimbursement cycle inefficiencies on to the consumer. This is evidenced by start ups like St. Paul's Athos Health - a service based solely on preventing larger providers from unnecessarily billing consumers for care that should be reimbursed by the funds in the insurance plan.
This is an essential addition to a claims reimbursement cycle practice that lacks the integrity to properly serve today's consumers long term care needs. This has become a forefront issue as Wisconsin struggles to implement State wide delivery. Stated simply- a claims reimbursement cycle that manufacturers:
- Providers not paid for services performed
- Consumers getting bills for received service that should be reimbursed by the plan
- Operating providers unwilling to contract stating claims reimbursement cycle deficiencies as the reason
is no longer acceptable. The lack of participating providers is pushing the Long Term Care Legislative Authority to place the existing claims reimbursement cycle under the microscope.
Estimates on the frequency of errors has moved from a numerical communication to a list of discipline specific providers unwilling to contract with the public (insurance) funded programs. This is supported by numbers of individuals eligible for service but unable to find a service provider.
The core of the problem is a claims reimbursement cycle that lacks process standards required to assure long term care delivery for our highest need population.
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