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Private/Commercial Payers

Policy and Financial Analysis to Support OHA Members

OHA's policy work with Ohio’s private health insurance companies focuses on these payers’ impact on our member hospitals. OHA's team works to reduce the administrative burden on member hospitals that provide care to the 57% of Ohioans with health care coverage through private insurance plans. Through the OHA Payer Scorecard program, we provide members with data for financial planning and decision making in their payer relationships. 

Questions? We Provide Answers.

Have a question related to a payer issue? Our OHA team is here to get answers for member hospitals. Email your question to Morris Ellington, OHA director of Health Economics & Policy, who leads our private payer relations.

OHA Private Payer Scorecard Project

Twice each year, OHA reaches out to member hospitals to collect payer performance data specific to each member organization. The data is used in aggregate form to:

  • Enhance OHA’s advocacy efforts by providing measurable data that will demonstrate the burden hospitals endure in their relations with the payers
  • Provide data back to participating members allowing them to benchmark their organization’s experience with a payer to facilitate any internal process improvements and to identify opportunities for outreach to payers to resolve issues.

Payer Information for Members

Our member hospitals need the most current information from Ohio's payers to efficiently process prior authorizations and billing for health care consumers across the state.

OHA's Health Economics & Policy team analyzes the reimbursement policies and claims processing of health insurers operating in Ohio and aggregates a quick-reference resource for our members. We summarize payers' updates and provide links to reference materials, by payer, here.

Pilot Projects: Collaborations to Improve Health Care Delivery and Outcomes for Ohioans

OHA's Health Economics & Policy team works with member hospitals and insurers to launch pilot projects that aim to improve health outcomes for patients while reducing the administrative burden on hospitals to process the claims or authorizations.

We value our members' and payers' creative thoughts and suggestions on potential pilot projects. Have an idea to share? Contact Morris Ellington.

New Pilot Projects

Humana Pilot Project Proposal:

Humana proposes to perform an audit of sample accounts from a facility to examine how the billed ED evaluation and management level matches the medical records with the goal of expediting future claims for the same service.

How the pilot works:

  • If a certain percentage of accounts (85%) are clean, meaning the medical record justifies the billed ED E/M level, then the facility is excluded from the algorithm for all ED E/M levels for one year.
  • Humana can run its algorithm and audit a facility’s accounts on an annual basis thereafter.
  • Facilities that are below the 85% clean claims level will be on a probation status for a period (e.g. 3 months).
    • After the probation ends, Humana can conduct another audit. If the facility reaches the set threshold of clean claims, it will be excluded from the algorithm for all ED E/M levels for one year.
* This pilot project is no longer accepting hospital participation at this time. However, if you have any questions or concerns, please email Morris Ellington.

Medical Mutual of Ohio Pilot 

Medical Mutual has agreed to work with a member hospital on the data collection process for the OHA Private Payer Scorecard survey to better understand the process and elements important to hospitals.

Medical Mutual will generate 10 scorecard data points from its internal data and compare it to the hospital's data. 

* This pilot project is no longer accepting hospital participation at this time. However, if you have any questions or concerns, please email Morris Ellington.