Posts tagged with UHC

I get a lot of little messages every day that I feel like I should save and/or share, but they don't add up to an entire blog entry (I don't like to do more than one a day, if that, as it feels like spamming). So, here's my house cleaning:

• The AAP has released the 2008 Immunization Schedule. You can read the details from Pediatrics here or get the PDF/chart here.
• Speaking of the Pediatrics journal, here's an interesting reprint about "Incorporating Quality Improvement Into Pediatric Practice." It's a few years old, but still rings true. I keep getting ideas about how to measure the value of preventive care, but I never follow through. For years, I just presumed the data was there, the connection being so obvious. What a surprise when I learned it hasn't been done! Someday.
• Here is an interesting site (thank you Dr. Stoller) that will give you a side-by-side summary of the health care positions and proposals for each of the presidential candidates who is still in race (I am disappointed that they drop those who have dropped out, as I'd still like to see their positions). Courtesy of the Kaiser Family Foundation.
• Thanks to SOAPM, I have this piece to share:
  

  In response to concerns raised by the AAP and several pediatricians across the country, UHC revised its clinical policy on palivizumab. Effective January 1, 2008, benefits coverage for palivizumab will now be aligned with the AAP recommendations published in the Red Book. UHC is in the process of sending notification letters to its physician provider network. A copy of the AAP letter to UHC can be accessed on the AAP Member Center, private payer advocacy page. Many thanks to SOAPM members for sharing information about the change.

  Thanks to The Verden Group for that text.

• Finally, Lynn@Eden sent out a heads-up to PedTalk about Merck pricing changes:
  

  Pricing up 4%, effective Mar 1, on Gardisil, MMR, Rotashield, Varivax
  Gardisil promo (if you purchase >70 doses) extended until Feb 29
  Time to negotiate with your inscos for an increase in reimbursement
  before you have to buy in at the higher price

Those of you who have the misfortune of having spent time with me know that I tell a lot of stories, often more than once. I also use the same punchlines a lot.

One little routine I've inserted into seminars, phone calls, and lunches a thousand times over the last decade is the UHC/Ingenix piece. "Sure, there is another place where you can get some of the data I'm talking about - Ingenix. You know who owns them, though, right?" Very few people have ever known before I told them.

I have always felt compelled to share my discomfort relating to the Ingenix data, before I even knew about the UHC connection. I remember buying that expensive CD program in order to look up pricing information. Remember that feeling from in your practice management education: "Holy cow, to do this right, I need a lot more data and these people have it on a silver platter!" In fact, they were my inspiration for creating the RVU calculators - I felt it a bit ridiculous that pediatricians should have to pay for RVU information.

Anyway, there are parts of the country where PCC has a concentration of customers or extra knowledge about a local market. Here in Vermont, for example. Or San Antonio, northern NJ, Tulsa, etc. Every time I checked the Ingenix software for the "usual and customary" prices...they just seemed lower than what I would have expected. Had they simply been different, some high and some low, I'd have understood. But it's always low. If there are only six pediatric offices here in our county and I know the prices to all of them, and Ingenix reports a lower median price - how is that?

Here's the other question: where does this data come from? How does UHC/Ingenix get CPT/pricing level data from places like Vermont, where they don't actually have a presence? Doesn't that seem odd? If the data isn't for sale (gross!) then how are they getting it?

For that random person hitting this blog who doesn't know what I'm talking about, you can hear NPR's take on Andrew Cuomo's investigation of UnitedHealthCare. Better, check out NY's press release. My favorite quote from it:

Cuomo’s investigation also found a clear example of the scheme: United insurers knew most simple doctor visits cost $200, but claimed to their members the typical rate was only $77. The insurers then applied the contractual reimbursement rate of 80%, covering only $62 for a $200 bill, and leaving the patient to cover the $138 balance.

The real question: is anyone surprised?

Update: the NY Times has finally gotten into the commentary.  My bet? This goes nowhere important.

From Susanne Madden, queen of The Verden Group:

I had an interesting conversation with a reporter at the WSJ this afternoon. She would be very interested in speaking any physicians who have experienced service and claim issues with UnitedHealthcare.

If anyone is interested, can you email me at this address?

If you read this blog, then I know you have had problems with UHC. Help us all out. Her address:

m a d d e n @ t h e v e r d e n g r o u p . c o m
[without the spaces]

It's been a rough week, especially over at PedTalk. The autism/vaccines "debate" has poisoned the waters of discussion pretty badly and I have a feeling that some of the anti-vaccine crowd is trying to cause some technical difficulty for us. They've done it before, so we'll see what Yahoo and others tell me (sorry for being cryptic).
To add to that, most of the news I had to share was negative. I had Dr. Stoller in the WSJ talking about how much UHC stinks (not really news to those of us in the business, but hey). Then there were the articles about primary care doctor shortages (which were linked to MA's new insurance requirement law, but I've asked my clients there about it and they don't report much). And so on.
I decided to share something helpful, positive to get my out of my doldrums and negative focus, so I have two things.
First, to prove that not all movie stars are anti-vaccine, here's a nice link from Salma Hayek (just putting her name here will attract all kinds of the wrong attention). Yes, I am cynical when I see that one has to buy Pampers to get the tetanus shot donated, but at least someone is aiming at the right target. I thank Salma for lending her name to this campaign (presuming she didn't get a bucket of cash). Perhaps she'll read this blog in get in touch. No? You don't think so?
The other thing I was working on was an all-in-one Immunization/Vaccine/CPT/ICD9/Manufacturer table. I have had this information in different places at different times and always make it hard to find. I suppose I could combine it with the CDC price list, perhaps I will. Please let me know if any additions, changes, corrections I can add to it! It provides a list of vaccines, with associated ICD9, CPT codes, descriptions, manufacturer, and product name. Handy dandy. Click below. My extreme thanks to Q, who helped me put this together (ok, she did most of the work).

Just as Dr. Stoller hit PedTalk with the info, I was reading the teaser over on FierceHealthcare:

Now, a consumer is raising the stakes a bit by attempting to get class action status for a suit against Ingenix itself.

I've written about my experience with the Ingenix "data" and their relationship with UHC, though I did conclude that this issue would go nowhere. Now that a consumer has gotten in on the deal, perhaps I'm wrong. I can only hope.

In the good news department, get this: Oxford just announced that they are changing the way their policy updates are communicated on-line. Instead of just listing the policies, they are providing a summary for each (like Aetna). This is much more human-friendly and will go a long way to improving their scores in the Verden Report. Given the proximity of this action to the release of the data which shows them scoring so poorly, I can only wonder what the coincidence level is. I'd like to think it was the Verden Group that pushed this into happening. Oxford would, of course, tell us that they have been working on this "for months" I am sure.

Dr. Rona Stein, in response to a request on PedTalk for a "good form [you] use to track time for coordination of care" was generous enough to offer the following form. It may not be the Magna Carta, but it works and I really appreciate her effort and willingness to share. Right-click links below for the version of your choice:

• Chronic Care Encounter Log (PDF - 38K)
• Chronic Care Encounter Log (OpenOffice - 11K)
• Chronic Care Encounter Log (M$ - 45K)

Thank you, Dr. Stein.

Meanwhile, I was catching up with a client on her continued negotiation with UHC. She has given them a short time frame to fix some real issues. What happens when a pediatric office manager puts her foot down and says, "No!"? Here are her words:

We met and we are waiting for them to get back to us with a proposal. Thanks for the help. They were really taken back over the information we had. They have been in touch with us almost everyday fixing our vaccine issues. Just waiting for the fee proposal. Holding my breath, but we are prepared to walk.

That last sentence is fundamental for their reason for success.

First, I am on the road this week - visiting clients, enjoying some upgrade work (keeps me fresh), and picking up a new pinball machine while our old one gets worked on. New Jersey is always an interesting place for me to visit, I must say. Pardon me for my brevity and inattention, meanwhile.

Earlier today, on PedTalk, Dr. Lessin posted an eye-opening PDF along with the commentary below:

I have attached a pdf of the latest Medical society of the State of

New York issue of News of New York. (This is the only way that I

could get the data).

If one goes to page 9, one will see a chart of starting salary by

specialty out of residency in NYS. At the very bottom, fully 30%

lower than any other specialty, is general pediatrics. We were 50%

below other primary care specialties and only a fraction of the

surgical specialties.

Who wouldn't want to practice here?

Yikes. Meanwhile, Dr. McGuire claims...stupidity? and looks like he will keep his hundreds and hundreds of millions of dollars. Hey pediatricians - that's where your money went. Maybe crime does pay.

Yes, I'm breaking my promise to post the appeal letter today. However, that's not the promise for which today's entry is titled. Something more important needs to be communicated.

I've written many times about Susanne Madden and her Verden Alerts. Why the world hasn't pounded down her door and signed up for her service is beyond me. Fortunately, in her own version of herd immunity, Susanne sometimes makes important information available to us all for free. Below, please find an update about some recent UHC payment/policy changes that will affect any pediatrician who participates with them.

Thank you, Susanne. The rest of you: start your engines. [Note that the Synagis change may even be retroactive.]

For those of you that are not Verden Alert subscribers, I wanted to make you aware of a couple of UHC policy changes that will affect Pediatrics:

Please note that 1. is titled After Hours and Weekend Care but only addresses services provided on an emergency basis . . .

1. After Hours and Weekend Care Policy

Under the current UnitedHealthcare policy for reimbursement of services provided in the office on an emergency basis, CPT code 99058 is reimbursed in certain places of service when reported with basic service codes. This CPT code has a status of 'B" (bundled into payment for other services not specified) on the National Physician Fee Schedule resulting in no additional CMS reimbursement. Effective in the fourth quarter of 2008, UnitedHealthcare will align reimbursement of this code with the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS). As a result, reimbursement for services provided on an emergency basis, CPT code 99058, will not be separately reimbursed.

Go to http://content.4at5.net/email_domains/unr/21553/hosted/reimburse_6.html

2. New Synagis Drug Procurement Protocol Effective July 1

A new protocol for the ordering, clinical coverage review and purchase of palivizumab (Synagis) takes effect July 1 for all participating physicians and health care providers. Beginning on that date, Synagis must be procured from our preferred specialty pharmacy provider, PharmaCare/CVS Caremark.

Palivizumab (Synagis) - Requirement to Use Participating Specialty Pharmacy to Obtain Synagis

UnitedHealthcare has selected PharmaCare/CVS Caremark, a national distributor of Synagis, as our preferred specialty pharmacy provider. PharmaCare/CVS Caremark's national network provides timely Synagis prescriptions and clinical services to meet the needs of participating physicians and our members. PharmaCare/CVS Caremark has been instructed to deliver Synagis consistent with UnitedHealthcare's Drug Policy for Synagis. PharmaCare/CVS Caremark works directly with our Clinical Coverage Review team in the Consumer Decision Support Advocacy unit to determine whether proposed Synagis use is consistent with the member's benefit plan.

Continued Use of a Non-Network Specialty Pharmacy for the Acquisition of Synagis Effective July 1, 2008, continued use of a non-specialty network pharmacy, wholesalers, or direct purchase from the manufacturer of Synagis, without prior approval from UnitedHealthcare may result in the physician or other health care professional not being reimbursed in whole or in part, as provided in the Participation Agreement. In addition, the physician or other health care professional must not bill our members for any amounts not paid due to non-compliance with the Synagis drug procurement policy.

Physicians who prescribed Synagis in 2007 will be sent a letter about the preferred specialty pharmacy providers to obtain Synagis and the drug policy for Synagis.

For more information, view the above protocol in the 2008 Physician Administration Guide and the drug policy at UnitedHealthcareOnline.com>Policies & Protocols> Medical Policies.

I am in lovely Columbus, OH, about to meet Dr. Lander, Donelle Holle, and some clients for dinner as we prepare for our pediatric coding and practice management event tomorrow morning.  We obviously won’t have the crowds we get in Washington or NYC, but it will be a pretty full room still!  If you are one of the blog readers, say hello.

Two vital pieces of pediatric insurance information for those of you who aren’t PEDCOUNCIL members or on the SOAPM mailing list.

Item 1:

UHC moves to enhance immunization administration payments
After receiving input from the AAP regarding low immunization administration pricing, UnitedHealthcare (UHC) found the main reason for this is that pediatricians are on contracts with fee schedules tied to 2004 CMS Medicare rates or prior years. UHC reported that, to a lesser extent, it also found that some markets set immunization administration pricing at a lower percentage of the CMS Medicare rates. Most markets are currently using 2008 CMS for physician contracting. UHC has identified those pediatricians whose contracts with fee schedules set at or prior to the 2004 CMS Medicare rates and will be working over the next several months to update the fee schedules and migrate those impacted to a more current CMS year in order to increase immunization administration pricing.

UHC will provide written notice of the fee schedule changes for immunization administration codes in conjunction with other fee schedule maintenance in some cases per the terms of the contract. UHC expects that this initiative will take several months in order to complete financial analysis, complete the revised contracts and mail to physicians, load the new rates and provide the appropriate notice per the contract.
The AAP will continue to dialogue with UHC regarding the timing of the effective dates of the updated fee schedules and to monitor UHC review of its vaccine payment methodology.

Item 2:

As follow-up to a recent meeting with the AAP, Humana has announced that it will revise its pediatric immunization payments, as well as pay for telephone care.

Vaccine payments: As of October 1, 2008, Humana will increase payment for pediatric immunizations that will based on a percent of the current average sales price (ASP). Humana will also reimburse vaccines that are not based on ASP to a percent of average wholesale price (AWP).  Details regarding reimbursement on the Humana National Drug and Biologicals Fee Schedule can be viewed by participating providers via the secure area of www.Humana.com ( http://www.humana.com/ ) In addition, for pediatric combination vaccines containing four or more vaccine components, Humana will pay the immunization rate plus an additional $11 to the allowable fee. This would not apply to those combination vaccines with fewer than four vaccine components (e.g., MMR
and DTaP).

This reimbursement methodology applies only to providers that have either received written notification or signed an addendum indicating transition to the Humana National Drug and Biologicals Fee Schedule.  For more information regarding the transition to the national drug schedule, please contact the Humana contracting representative in your market.

Telephone care: Humana has established processing rules for the new telephone CPT codes 99441-99443. these codes will be processed as covered services; however, the and the plan member will be responsible for standard office co-payments or other cost-share amounts applicable to any other office visit. Medicare does not cover those telephone consultation codes nor does the Department of Defense (TRICARE) so neither Humana Military Healthcare Services (HMHS) nor Humana Medicare will cover the telephone care codes. Only Humana commercial health plans will provide payment for telephone care. Payment for the telephone consultation codes will be based upon the current RBRVS system.

For information on coding and billing for telephone care, see the AAP Payment for Telephone Care Toolkit, available on the PMO at:  http://practice.aap.org/telecarepmt.aspx

AAP private payer advocacy will continue to work with Humana and shareadditional details of these payment enhancements.

A lot to comment about.

• First, about UHC. Rather, I should say, “It’s about time, UHC.”  Although I suspect their excuse is, technically, true, it’s totally bogus for them to pretend that they didn’t realize what is going on.  Sure, this is good news and I applaud the AAP for keeping up the fight.  But ask yourselves this: if so many of these pediatricians are tied to 2004 (before the big imms admin jump), how did UHC calculate the values of the 90465 and 90466 which did not exist in 2005 and never existed with the lower RVU rates? Obviously, UHC made a deliberate decision to lock peds into 2004 during their big push to get everyone on RVU-based schedules, because it saved them millions of of dollars. DUH.
• Whoa, Humana.  A couple things:
  • ASP!  Finally!  Someone using data that’s at lease close to what the pediatricians pay.  Crazy talk.
  • Even crazier: Humana will pay extra - and decently extra - for combo vaccines with 4 or more components?  <thunk> I just passed out.  Sure, the imms admins are rolling towards counting antigens anyway, but Bravo Humana! for doing the right thing in the first place.  There is no longer an incentive for docs to avoid the combo vaccines (children throughout the country rejoice).  Good medicine.  Who made this sensible decision and, as a result, should fear for his or her job security?
  • Craziest: Humana pays for telephone care. I broke the boldface out for that line and went back and highlighted other things as a result.  What has gotten into these people?!  [I mean that in a good - no, great - way.]  It’s official - a national payer will cover telephone codes.  Awesome.

Honestly, I am going to tell all my friends to choose Human if they can.  Not because these dollars make some huge difference, but because it’s a sign that someone in that company gets it and they should be applauded.

More tomorrow, perhaps “live” from the coding conference!

Let me open this blog with a summary of the phone call that inspired me to begin recording my experiences consulting with private pediatric practices around the country.

A long-time customer of PCC’s called me from San Antonio two weeks ago. I’ve always enjoyed my conversations with him, as it’s delightful to work with someone who clearly cares so deeply about his patients and his practice. It’s not that we see eye to eye on everything (in fact, I suspect we differ politically as much as two people can), but he calls me from time to time for help with his practice and I’m glad to help him.

In this instance, he’s decided to open the can of worms known as United. Somehow, he found out that the contract he renegotiated (with my help) three years ago was never fully implemented…apparently, while the other practices in town - and around the country - were being paid with RVU rates set for 2004 and beyond, he is still using 2001!

For those of you not the in the pediatric world, that means that thousands of immunization administration codes (90471, etc.) have been paid by United at, say, $5 when they should be $10-20, at least. For pediatricians, that’s real money.

So, he called United and what did they say? “Gee, we must have missed you when we updated everyone. Sorry about that.”

Sigh. No offer to fix it retroactively, of course. They only remove payments that way.

What I can’t understand is how they paid the 90465 and 466, for example, which had NO values until, what, 2005?

I called into the practice and, ignoring all of the other problems with the fee schedule (<100% of Medicare, San Antonio’s bogus placement in the “Rest of Texas”, etc. ), I’d put the loss for this practice at somewhere between $10,000 and $20,000 on just the 90471 and 90472 codes alone.

And that’s when I said, “I need to start writing these things down.”