I have a backup of pediatric benchmarks (a really cool location-adjusted revenue one is coming), but some items I have to get out of my queue:
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.
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]
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.
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.
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.
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.
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
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.
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!