From the
President
BRUCE A. SCOTT, MD
GLMS President | [email protected]
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