Syndicate content Tell a friend about Pedsource!


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.

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

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>Policies & Protocols> Medical Policies.

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.

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]

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 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:

  • A WSJ view of a program being put together by some major employers (Bridges to Excellence) to promote the use of the medical home.  Skipping the middle-man (known as the insurance companies), why not pay physicians part of the savings from keeping employees healthy?  The faster we move away from health-insurance-as-a-means-of-cash-flow-management, the better.  One of our clients in Maryland used this program to pay for their EHR two years ago...
  • UHC has extended its relationship with Epocrates.  I had head from some clients how "typical" it was of UHC for it to cancel the relationship with the popular hand-held drug reference, it's good to see that it has done the smart thing.  Note that SOAPM, PPAAC, and, particular, Dr. Anne Francis were instrumental in getting this to happen.  Good work.  I don't understand what the down-side is to UHC, afterall.