Louisville Medicine Volume 62, Issue 8 - Page 7

From the President BRUCE A. SCOTT, MD GLMS President  |  president@glms.org FAIR CONTRACTING J ane Patient signs in at the front desk, presents her insurance card and begins completing the pile of now compulsory forms. After the staff checks the eligibility of her specific plan, Jane is informed that this physician is not a “participating provider” and is not allowed to see her. “But his name was on the list from the insurance company when I signed up for this plan… You mean, I have waited three weeks, taken off work today, and now the doctor refuses to see me?” Jane is angry – at the doctor, and more specifically, the front desk clerk who explains, “we do participate with most of the plans from that insurer but not that particular plan.” Similarly, after providing care for a patient, physicians all to often discover that he or she is not a participating physician in that particular version of that specific carrier’s plan. I saw a facial trauma patient from a Southern Indiana emergency department on an urgent basis in my Louisville office and operated on her at a Louisville hospital only to learn that I would not be paid for my services rendered in Kentucky. Although her insurance card said “Multi-State,” her carrier only paid for services rendered in Indiana. My error, I should have prioritized checking that fact before putting her face back together. An oncologist learned from a long-term patient that the patient could no longer receive care from her because the oncologist had been dropped by the insurance company’s plan without any notice or justification. An ophthalmologist found out he was apparently listed as a participating physician in an insurance plan that was previously unknown to him only when a patient presented for an appointment with an insurance card from that plan. Another physician saw a patient in January and again in February and March; each time the insurance card presented by the patient was verified on the company website. However, the claim was denied because the patient never actually paid the premium, so the health plan canceled the policy retrospectively. All of this equals good business for the health plans but heartache and hassle for patients and physicians. Unfortunately, none of this is rare. A recent study published in JAMA Dermatology, (December, 2014)* found only 26 percent of listed “participating physicians” were actually practicing at the address listed and accepting patients from the specific plan. According to The Wall Street Journal (November 26, 2014, page A3), doctors shown as “participating” included physicians that were not accepting the plan, were in a different specialty or location, were retired or even dead. The health plans responded that “it is difficult to keep the lists current,” yet they seem to be able to determine quickly which doctors are not in network so they can deny payment. I would note that to meet state and federal regulations, these same health plans are supposed to have an adequate network of providers. In fact, they often proudly advertise the scope of their networks. Last year, whether you know it or not, you likely received a “Dear Provider” letter from a prominent health insurance company. That letter, which you may have discarded as another piece of junk mail, notified you that unless you provided written objection within 90 days, you would be deemed to have accepted participation in the new plan, which incidentally included a significant reduction in payment. The Greater Louisville Medical Society (GLMS) and the Kentucky Medical Association (KMA) have been down this path before. A few years ago, the same insurance company decided if you wanted to participate in one of their plans you had to participate in all of them. The KMA, spurred on by a GLMS resolution, got legislation passed declaring it unfair trade practice for an insurer which offers multiple health benefit plans to require a physician, as a condition of participation in one plan, to participate in another plan, and required insurers who amend an agreement to give at least a 90-day notice. These were obvious steps in the right direction. The American Medical Association (AMA) continues working on regulations that prohibit the formation of networks based solely on economic criteria and ensure that, before health plans can establish new networks, physicians are informed of the criteria for participating. At its recent meeting, the AMA passed a resolution to require health plans to provide patients with an accurate