21.2% Medicare Pay Cut Will Take Effect Monday
Saturday, February 27th, 2010February 26, 2010 — Unless a minor bipartisan miracle happens in Congress over the next few days, physicians will go over the cliff on Monday. That’s when a scheduled 21.2% reduction in Medicare reimbursement takes effect.
A recent poll conducted by several medical societies representing neurosurgeons, for example, revealed that almost 40% would cut back on seeing new Medicare patients if reimbursement continues to decline, while 18% would stop accepting new Medicare patients altogether. Another 27% said they would treat fewer established Medicare patients.
Medicare Eliminates Consultation Codes
Monday, January 11th, 2010CMS (Centers for Medicare and Medicaid Services) announced the elimination of consult codes. Officially released and documented in Change Request “CR 6740″as of January 1, 2010 consult codes will be eliminated from the Medicare fee schedule. Medicare will no longer recognize or pay for services billed with consult codes 99241-99245 or 99251-99255.
CR6470 impacts only Medicare claims as of January 10th 2010, Medicare Advantage plans are likely to follow the Medicare rules. Medicare claims will not use consult codes, while private payers will (for now.) Verification of patient insurance prior to the physician visit is more critical than ever.
Declining Doctor Reimbursements Continue Closing Offices
Wednesday, September 10th, 2008 For 26 years, Dr. Joseph Lalka has been a family doctor, treating 3,000 patients in his cramped office in Chatham, N.Y., a small town nestled in the rural northern part of the state. But Lalka recently told his patients he is taking down his shingle and closing his practice. He says he no longer can afford to maintain a family practice.
Now his patients fear a future without the man who has cared for some of them for a quarter of a century. And they say they are angry at a system that has forced their doctor to leave because of escalating operating costs and declining reimbursements. Lalka, 54, says that with an income of only $60,000 last year, and little opportunity to expand his practice, he no longer is able to make ends meet.
The physicians contract is at the center of the reimbursement issue; specifically “payment terms.” This has been un-manageable for many physicians; it’s not that they don’t care; it’s that their practices have turned into revolving doors to try and keep up with declining reimbursements and the demand for healthcare.
Consider this, a family practitioner can spend up to an hour with one patient and be reimbursed in the area of $25.00; factor in expenses and you see the problem. At the end of the day physicians must identify and manage these contracts. It is no longer sufficient to trust their income to others.
If Dr. Lalka, and others like him, had the necessary data; the outcome could have been far different.
Yet Another Fine
Thursday, August 14th, 2008 Yet another payer has been ordered by state regulators to pay restitution of $3.9 million to thousands of members and a $250,000 fine for underpayment of claims related to care in out-of-network hospitals and other medical facilities.
State Insurance Commissioner Mike Geeslin ordered the health insurer to make the payments over the next several months and specified that if they don’t total at least $3.9 million, the balance must be paid to the state as an additional fine, reported the Dallas Morning News.
Doug Danzeiser of the Texas Department of Insurance said the underpayments date to Jan. 1, 2004, and involves thousands of members in Texas enrolled in Preferred Provider Organization plans.
Dallas Morning News, August 9, 2008
Healthcare Payment Reform
Thursday, July 24th, 2008 In many ways, the nation’s current healthcare payment system creates inefficiencies by adding cost and complexity to healthcare administration. Achieving payment system reforms will require a level of cooperation among all stakeholders.
In the current volume-based payment system physicians and others who provide high-quality, efficient care and thereby reduce the volume of patient services, receive reduced payment. The payment system encourages competition among healthcare providers for high-margin services, leading to increased fragmentation and, in some cases, an overuse of those services.
Principles of a New Payment System
1. Payments should encourage and reward high-quality and efficient care.
2. Payments should align incentives among all stakeholders to maximize the efficiency.
3. Payment systems should balance the needs and concerns of all stakeholders.
4. Payment processes should be simplified, standard, and transparent.
Only by operating within a shared framework of principles and goals will meaningful change be possible.
Virtual Office Visits
Friday, July 4th, 2008 The doctor doesn’t have to see you now. Thanks to new technology, patients may not always need a face-to-face visit with their doctor to get the care they need.
And thanks to a growing awareness of this fact on the part of health plans, structured, Internet-facilitated and reimbursable “virtual visits” are on the verge of entering mainstream medicine. Virtual visits also are seen as a tool that will save money, provide convenient care and maybe do something to solve the problem of patients not having access to their doctors.
This is especially true in Minnesota, where five of the six largest private health plans reimburse physicians about $35 per virtual office visit, and the last holdout announced that it will soon join the club. Unresolved, however, are issues over standards for billing and legal jurisdiction matters concerning doctors conducting e-visits during travel to states they are not licensed to practice in.
Health information technology vendors are helping to bring the parties together, and a message is being spread that virtual visits benefit patients by offering affordable and convenient access to their doctors; help providers more efficiently process routine cases; aid employers by reducing absenteeism created when workers take time off to see their physician; and—perhaps most significant—assist insurance companies in saving money.
“I would hope that 100% of the companies will be doing this in the next few years,” said independent family physician and e-visit advocate Michelle Eads of Woodland Park, Colo. “Once the insurance companies get it through their thick skulls that it saves money, they’ll be more than willing to do it.”
Eads is also the sole practitioner in a pilot study Kaiser Permanente of Colorado Springs is conducting exploring the use of virtual visits by in-network independent physicians. She receives $50 for an online consultation and said preliminary figures from 2006 show that Kaiser is saving between $70 and $120 on each virtual visit.
Internist Paul Tang, the vice president and chief medical information officer of the Palo Alto (Calif.) Medical Foundation, believes employers should pay more attention. He said, in a study, his organization found that for every $1 employers invested in virtual-visit programs, they received a $4.50 return—mostly in the form of savings generated from having less lost productivity.
Eads, speaking at the AAFP’s annual scientific assembly in Chicago earlier this month, said it takes about 16 minutes to complete the typical virtual visit, and that they have been particularly useful in monitoring patients with hypertension and depression. Besides chronic conditions, Eads said these visits are also helpful for patients who work nights or who are just under the weather.
“I live in the mountains,” she explained. “Some people don’t want to drive into the mountains just for me to say ‘Yes, you’re sick.’ ”
E-visits also work out for patients without insurance who find the $50 online-consult fee easier to swallow than the price of an office visit, Eads said.
Miami-based family physician Bernd Wollschlaeger has nothing but self-pay patients in his cash-only, paper-free practice, and he said his patients don’t mind paying for electronic communication. Fees start at $15 to $20 for a prescription refill, $25 for chronic condition management, and then go higher the more complex the task. “Most people in my practice understand that my time is money,” Wollschlaeger said. “I’ve never heard a complaint.”
How Are Employer Medical Premium Dollars Being Spent?
Friday, July 4th, 2008 The Texas Medical Association and the National Federation of Independent Businesses have teamed up to help their members, most of which are small business owners, find out how much of their medical premium dollars are actually being spent by insurers on health care.
Thanks to a little-known piece of legislation passed by the Texas Legislature in 2007, insurance companies must disclose this information, reported the Houston Business Journal. TMA and NFIB hope that if enough small business owners demand this information and then use it to contest premium-rate increases or to shop for better pricing, it might be a small step toward more transparency and competition in the health insurance market, the Business Journal added.
Houston Business Journal, June 13, 2008
Physician Costs and Getting Paid Properly
Friday, July 4th, 2008 Administrative complexity and inefficiency are major cost-drivers in a largely fragmented health care delivery system. A typical physician practice contracts with a dozen or more health plans and must contend with each payer’s way of contracting, credentialing, preauthorizing, coding, billing and reimbursing.
Health insurer contracting and billing represent the major sources of administrative burden for physicians. Physicians divert substantial resources – as much as 14 percent of their total revenue – to ensure accurate insurance payments for their services, according to the AMA’s first National Health Insurer Report Card on claims processing, released last month.
Even in a typical physician office without a fully automated practice management system, replacing traditional paper and telephone calls for insurance administration – i.e., claims submission, referral and preauthorization requests, and patient eligibility verification – with electronic transactions brings a per physician savings of more than $42,000 annually, according to a Milliman Inc. study released January 2006.
Some administrative burden is self-imposed by physicians, particularly small or medium-sized practices that are busy seeing as many patients as possible and don’t take the time to think about standardizing their workflow for efficiency.
The main focus of administrative simplification initiatives has been standardization of data flow between physicians and health insurers. Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
Rating Payers
Saturday, June 28th, 2008 Some health insurance companies rate doctors on their performance. Now doctors are turning the tables.
The American Medical Association issued its first health insurance report card at the group’s annual meeting Monday. The primary focus is on how quickly and accurately doctors get paid.
“Physicians are spending 14 percent of their total revenue to simply obtain what they’ve earned,” said Dr. William Dolan, an AMA board member.
The report card is an effort to reduce the cost of claims processing to doctors and help them as they negotiate contracts with insurance companies, he said. The report card will help patients if it reduces wasteful administrative costs, Dolan added.
The report card compares Medicare and seven national commercial health insurers on the timeliness and accuracy of claims processing. It is based on a random sample drawn from 3 million claims.
There are no grades like A, B and C, and many of the technical measures may not mean much to most patients. But business leaders and health policy makers are interested in cutting an estimated annual $210 billion in wasted administrative claims processing costs, AMA leaders said.
Four years ago, Dr. Marcy Zwelling got so frustrated with the time and cost of making sure she was paid accurately by insurers that she stopped dealing with them. She now runs a so-called “boutique” practice. Most of her patients pay her an annual fee out of their own pockets.
“The best thing is, I get to be a doctor” instead of a claims processor, said Zwelling, of Los Alamitos, Calif. She says she doesn’t make any more money than she did when she accepted insurance, but she has more time with patients.
UnitedHealthcare had the lowest rate of contract compliance, according to the AMA report. About 62 percent of medical services billed were paid by UnitedHealthcare at the contracted rate, compared with 71 percent for Aetna and 98 percent for Medicare.
UnitedHealthcare spokesman Gregory Thompson said doctors and their billing services share responsibility for prompt payment. “Data show there is often a significant lag time between when services are provided and physician claims are submitted,” he said.
He said UnitedHealthcare has improved its electronic claims systems and noted the AMA gave the company higher ratings on other measures.
Medicare performed better than the private insurers in most areas, said Dr. Lawrence Casalino, a University of Chicago health economist and former physician. Commercial insurance plans compete by promising employers that they are tough on holding down the cost of claims, he said.
“There’s no question that administrative costs for doctors and the country would be a lot lower in a single-payer system,” Casalino said in an interview after the meeting. But a market-based system has advantages of competition, choice and innovation, he said. “Are the benefits enough to justify the cost?”
Peter Lee of the Pacific Business Group on Health welcomed the report card, but said he hoped the AMA would look at a broader range of areas that would be helpful to consumers.
“Increased payments to physician’s means increased premiums and increased costs in a system that is spiraling out of control,” Lee said.
Susan Pisano, a spokeswoman for America’s Health Insurance Plans, said that for claims to be processed accurately and quickly it takes two parties: insurers and doctors.
She complained that while insurance companies that rate doctors generally share the information with doctors before they make it public, the AMA did not share its report with insurers before releasing it online Monday.
By CARLA K. JOHNSON, Associated Press Writer
AMA (PSA) National Health Insurer Report Card
Credentialing – To Delegate or Not To Delegate
Monday, May 5th, 2008 The National Committee for Quality Assurance (NCQA) sets the standard for credentialing in managed care. Defined as the “process by which a managed care organization (MCO) authorizes, contracts with, or employs practitioners who are licensed to practice independently to provide services to its members”, credentialing simply means making sure that a practitioner is qualified to render care to patients. Each MCO sets its own qualifications and then structures its processes to ensure that the practitioners meet these qualifications.
This blog entry is intended to provide the reader with an overview of credentialing requirements and the credentialing process, including delegation of some or all of the credentialing activities.
Each managed care organization (MCO) is responsible for establishing the criteria for participation within the health plan. The basic elements for a physician are likely to include the following:
1. Valid and current licensure
2. Appropriate education and training
3. Curriculum Vitae (CV)
4. Clinical privileges at a hospital
5. Valid Drug Enforcement Agency (DEA) certificate
6. Board certification (if required by the MCO or specified by the practitioner)
7. Work history
8. Malpractice insurance
9. History of liability claims
Regardless of the guidelines set, the MCO must put a system in place that ensures that its practitioners meet these standards before they are accepted as an active provider within the health plan. This system or process is commonly referred to as credentialing.
The credentialing process is just that – a process. It consists of a series of activities designed to lead to a decision to accept or reject an individual’s application to participate in the MCO as an active health care provider. A simple credentialing process is outlined below:
Application – Practitioners expressing an interest in participation with the MCO, and/or practitioners who meet the MCO’s organizational needs and administrative requirements, are invited to apply.
Initial Screening – Before proceeding with the next step, the application is reviewed to determine that it is complete.
New Provider Site Visit – The applicant is notified that a new provider facility assessment and medical record keeping process audit must take place.
Primary Source Verification – NCQA stipulates that seven criteria must be verified from the primary source because they identify the legal authority to practice as well as the relevant training and experience. MCOs may choose to use an external agency to collect information from the primary sources. If this is the case, the MCO has delegated this component of the credentialing process and must assume oversight functions. The criteria that require primary source verification include:
1. Valid license to practice
2. Status of clinical privileges at primary admitting facility
3. Valid DEA certificate, if applicable
4. Education and training of practitioners
5. Board certification if the practitioner states that he/she is board certified
6. Current adequate malpractice insurance
7. History of professional liability claims
File Preparation – Immediately following the initial screening, the file is prepared for presentation to a Credentialing Committee.
Data Entry – After all required data elements have been received, the individual practitioner’s credentialing file is entered into the MCO’s credentialing database and prepared for presentation to a Credentialing Committee.
The Decision – The decision to accept or reject an individual’s application is made by a Credentialing Committee.
References:
National Committee for Quality Assurance, The 2007 MCO Standards and Guidelines and Survey Tools
Related Web Site:
http://www.ncqa.org/ (NCQA)
