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How COVID-19 warped payer-provider contract negotiations
Modern Healthcare Illustration / Getty Images
The COVID-19 pandemic brought on a year of thanking healthcare workers. In Chicago, residents held nightly light shows thanking their providers. In New York City, people sang in the streets.
A year later, some experts believe health systems may be using their post-COVID-19 publicity glow to pressure insurers into rate increases, pointing to a rash of recent tense negotiations erupting into the public sphere. That s something we need to watch out for the, kind of the afterglow of public support, and then the argument that we lost money, we need to make it up, said Glenn Melnick, a professor of healthcare at the University of Southern California, who conducts research on payer-provider negotiations. I do think that we will see that this year and next.
In
Jessica U. v. Health Care Service Corp., a Montana district court held that an ERISA plan administrator improperly denied benefits for mental health residential treatment based solely on so-called Milliman Care Guidelines that were not included in the plan documents.
The Milliman Care Guidelines ( MCG ) are a set of health industry best practices, guidelines and diagnostic criteria published by MCG Health for providers and health plans. Although the MCG are widely used by health care professionals, the
Jessica U. case illustrates that plan administrators must use caution when relying on the guidelines, or other materials outside of the plan, as grounds to deny health benefits.