Posts tagged with lawsuit

[Before I begin, it looks like there might be an important RVU update later today!]

From hmosettlements.com:

On October 19, 2007, Highmark Inc., and Highmark West Virginia, Inc. d/b/a Mountain State Blue Cross and Blue Shield (“Highmark"), entered into a Settlement Agreement with physicians. The settling parties filed their Joint Motion for Preliminary Approval of Settlement on October 23, 2007; the court issued its preliminary approval order on November 19, 2007...

The deadline for submitted claims is February 27, 2008. Any questions regarding the settlement should be directed to the Highmark/Mountain State Settlement Administrator at 1-866-486-1725.

To make a long story short:

The Complaint in the Action alleges, among other things, that between 1999 and the present, the Blue Plans, among others, engaged in a conspiracy to improperly deny, delay, and/or reduce payment to physicians, physician groups, and physician organizations by engaging in several types of allegedly improper conduct.

I am shocked, shocked I tell you, that the insurance companies might conspire to deny, delay, or reduce payments! Apparently, based on your claim $$ volume from 2004 through 2006, you are potentially entitled to money you earned, but was manipulated from you by BC/BS, Highmark, etc. You can find their claim form on-line, too.

Your deadline is Feb 27, so don't delay.

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. I opened it up and though, "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.

During the production of this blog, I have noticed a certain amount of serendipity with the information I take the time to share. If I mention, say, the concept of concierge medicine, I'll get a call the next day out of the blue from a client who is working on it and shares her experience with me.

Yesterday, I started the first of two or three posts about the use of the 96110 CPT code in pediatrics. It's symbolic of a series of codes (any of the screening codes, after hours codes, telephone codes, etc.) that many pediatricians perform, but don't record. As you can see from the graph I posted, only ~30% of PCC customers bill for it presently. Here, in her own words, is Dr. Stoller's proof for why you should bill everything all the time:

I got good news today from ... the Cigna class-action facilitator. I (and several other pediatricians) filed a grievance with Cigna stating that bundling of 96110 was not in compliance with the settlement (I have one pending with Healthnet also). Well, today I heard that effective 5/1/08 Cigna is paying pediatricians separately on this code AND I have prevailed in my grievance and will get paid for all my 96110s I submitted to Cigna retro to 2005 (or whenever I first started billing it)! I just ran ira [a PCC report program] - I will be able to submit 819 charges to Cigna - if they pay $20 per charge that's a little extra change. I hope this help me prevail with Healthnet, too. And only the docs that actually filed the grievance get to file for all the retro charges - everyone else benefits as of 5/1/08.

Like I said, I can't make this stuff up.

So, thank you Dr. Stoller, on behalf of the rest of us. It's time more and more pediatricians get paid for doing this important work. And congrats on having the foresight to always bill for this, even when you weren't getting paid...it just shows that diligence pays off. BTW, the Cigna settlement is one of the earliest things I blogged about - wow, does that seem like a long time ago. And this isn't the first time Dr. Stoller has busted the inscos.

I like days like this.

It started when Susanne Madden sent me this "nice" message from Horizon to help me warn our clients about games Horizon continues to play.  Bottom line: they expect to stop paying for -25 or -59 modified codes starting May 10, 2010.

Two minutes of email exchange led the helpful Dr. Stoller to send me this announcement from MSNJ.   Good work.

I would love to have been in the room when the folks at Horizon decided to break the rules of their settlement.  "I wonder if any of the docs will react?  Let's try this!"  

More importantly, though: there shouldn't need to be a class action lawsuit to keep these bozos from flouting the CPT rules.  This is bad medicine and it makes the doctors and patients pay the price.  Shame on you, Horizon.

A week ago, one of our clients who retired called us out of the blue to ask if the server that they used 5-10 years ago could be booted up to extract some UHC-specific data.  I won't get into the details of what it takes to resurrect an RS/6000 (the good ol' days!), but I did want to learn more about why they wanted the data.

Turns out that that class action lawsuit against UHC for out-of-network claims that I'd heard about, but didn't understand, has moved forward quite briskly.  Fortunately, our friends at The Verden Group put together this great memo for practices who might need some guidance.  You have until October 5, 2010 - which is a very, very special date - to respond. Get on it!