verden alert

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.

The Verden Quarterly Report (Q2 2008) has been released! This is an amazing resource and the little comments about each ranking (in the blue box, off to the side of each page) are quite enlightening. And the price is right. Note that Oxford gets a most improved award, a distinct example of what I call the Verden Effect.

Make sure you have the latest copy of this guide when you do your insurance contract negotiations.

Oh, here's the press release:

The Verden Group Releases Second Insurer Ranking Report

Nyack, NY, 07/22/08 - The Verden Group has converted its proprietary Verden Alerts data into a single, free report that assesses the financial impact of thirty four major medical insurers' policy changing on their networked physicians and practices.

The report is available at http://www.theverdengroup.com/Reports/ManagedCareReport_Q208.pdf

The goal of the Verden Ranking system is to evaluate how insurance companies (payers) behave from the perspective of physician practice management. The data used to rank the payers comes directly from the companies themselves, as gathered by the Verden Alert subscription service. The Verden Alerts monitor insurer sites for any policy and procedure changes and alert subscribers based on their participation and specialty whenever changes are posted.

"Until now, medical practices who accept insurance have been working mainly in the dark when it comes to the policy and procedure changes insurers make," says Susanne Madden, Verden Group CEO. "The stakes are too high to allow it to continue. Insurers make astronomical profits by not passing through premium dollars to those that render care to insurers' members. Before we analyzed our Verden Alert data and created this report, there was no source for identifying policy modification trends - and the impact on physicians - except through anecdotal evidence."

The Verden Group summarizes the results into five key metrics important to any medical practice: Cost to Provider, Volume of Change, Clarity of Communication, Notification Period, and Posting Integrity. Then, a score is accumulated for each insurance company depending on the severity of the issue. For example, points are added as the volume of policy changes increases or as the changes negatively impact medical practices. Ultimately, the payers with the most points are, at least, the most cumbersome with which to do business.

Madden believes that having quantifiable data about how payers treat their networked physicians is a vital piece of knowledge to any medical practice. "Physicians should use this data to help challenge policies as they are being made, rather than just letting Payers set the agenda based on their own business initiatives. Not all payers are the same. Some

networks are managed worse than others and physicians can now make strategic decisions about which ones to participate in. The Rankings are an accountability tool to help aid in that decision-making."

For additional information on The Verden Group and the Verden Alerts, contact Susanne Madden or visit

www.theverdengroup.com.

A couple weeks ago, the Verden Alert gave me this little notice about Oxford: