Provider Network Forum

Laura then opened up the discussion, drawing upon a number of different issues affecting hospitals, clinics and insurance partners. The forum’s first topic identified particular factors that hinder providers’ operations, including insufficient communication about coverage, particularly when it comes to pre-existing conditions, and the differences between travel policies and health plans. The medical providers highlighted that having a table of benefits – which could be accessed on the website, for example – would be particularly helpful in clarifying the coverage included, as geographical delay in email or phone communication can hinder patient assistance and claims clarity.

However, payers noted that there is sometimes a reluctance to share exactly what is covered in a policy as this could encourage fraud through overtreatment and exploiting of benefits. Instead, providers suggested that standardising definitions within policies, such as categorising different treatment needs, would help tackle cost discrepancies.

The panel asserted that hospitals were likely discriminating against patients based on their nationality

The second topic explored the growing challenges surrounding medical provider billing in Mexico, with providers in Mexico increasingly leaning towards US cost structures. Some medical providers in the region will refuse to treat patients without a guarantee of payment (GOP), then after treatment, will inflate the cost to three times the original agreed GOP, and harass the patients for this cost. This negative customer experience is something that insurers desperately want to avoid, but they also need to balance this with reasonable medical costs.

The panel asserted that hospitals were likely discriminating against patients based on their nationality. It was suggested that many Mexican hospitals were not honouring the national agreement to allow a central organisation to do their hospital billing – one which was originally instated to ensure fair medical pricing. Instead, hospitals will get the patient to sign a disclosure agreement saying they are happy for a different company to do the billing for the hospital, and so the medical costs are extremely high. Moreover, although the Procuraduría Federal del Consumidor (Profeco) exists to put some legislation in place, the organisation is conciliatory and exclusively represents the consumer, and so insurers are not able to file a complaint to Profeco.

As a solution, the panel discussed instating legislation making it difficult for organisations in Mexico to carry out these activities, but more importantly, they highlighted that communication with both Mexican hospitals and travelling insureds is key to tackling the conflict. And so, the forum came round full circle, highlighting the importance of enforcing positive relationships between providers and payers as one of the key solutions to ensuring fair prices for all.

And though both teams performed spectacularly, not everyone can be a winner. With two rounds and 174 points, the international provider team came second, while the payers were crowned the victors of the Provider Network Forum, with three rounds and 255 points.