Date: Fri, 22 Oct 1999 11:24:25 -0400 From: daniel becker Subject: [c] Only paid for Acute low back [United Healthcare] Well, I just had my first "we only pay for acute low back injury". It is good old UHC. Unfortunately, we weren't made aware of this limitation until after the billing for an acute knee injury. (2 lousy visits that obviously are braking the bank for the down trodden victimized insurance industry) I guess UHC figures they can save more money by having their insured go to a provider which receives higher reimbursement from them. Amazing! Dan Becker, DC, DABCN ------------------ From: "ChiroView" Subject: Re: [c] Only paid for Acute low back Date: Fri, 22 Oct 1999 19:55:04 -0700 In performing UR nationally, about 28 states require the UR company to be state certified. That is no small task. I have put together a document that outlines what we do regarding method, criteria ,appeal etc. I don't know of another small carve -out[doing phys med only v. companies that do it all like CorVel, IntraCorp etc] that has gone through this exercise because it's very cost prohibitive. Some states charge $2000-3000 dollors per year. My point is if you are in a position in these states to do UR and to deny services, you must be certified by the state. Many states require either a discipline match, or a clinician skilled in prescribing that form of treatment, or even a discipline match by a clinician with a license in that state. There are many different levels of UR, ie starts of with software, claims adjuster, nurse case manager, general practitioner, then finishes off with specialist. The only way to deny tx is to have the physician authorize that denial, and if it's appealed, there almost always has to be a specialist/discipline match involved. If you don't go about it this the right way, the payer or UR entity is subject to a huge fine. I put this out there to you to see if things are being done the right way. Sigmund Miller, DC ----------------- Date: Fri, 22 Oct 1999 20:31:37 -0400 From: daniel becker Subject: Re: [c] Only paid for Acute low back Nothing personal, but feel free to tell them that. In fact, at a meeting I attend with the #2 and #3 person at our Dept of Health last spring the response was: We can't tell them what to pay for. Yet we have a quality assurance act that reads as follows: CHAPTER 23-17.13, Health Care Accessibility and Quality Assurance Act SECTION 23-17.13-3 (3) All health plans shall be required to establish a mechanism, under which providers, including local providers participating in the plan, provide input into the plan's health care policy, including technology, medications and procedures, utilization review criteria and procedures, quality and credentialing criteria, and medical management procedures. (7) A health plan shall not exclude a provider of covered services from participation in its provider network based solely on; (a) The provider's degree or license as applicable under state law; Now, I don't know about anyone else out there, but this basically says, that 1. local providers are to determine local standard of care (which means what will and will not be covered) and 2. that if the plan pays for the service, and you have a license to do it, they have to let you participate. Our DOH had ignored #1 and stated that #2 does not mean that they have to pay us for it as they can't tell the insurers what to pay for. Of course, we also have the following: CHAPTER 6-13.1 Deceptive Trade Practices SECTION 6-13.1-1 § 6-13.1-2 Unlawful acts or practices. ­ Unfair methods of competition and unfair or deceptive acts or practices in the conduct of any trade or commerce are hereby declared unlawful. § 6-13.1-1 Definitions. (3) "Person" means natural persons, corporations, trusts, partnerships, incorporated or unincorporated associations, and any other legal entity. (4) "Trade" and "commerce" mean the advertising, offering for sale, sale, or distribution of any services and any property, tangible or intangible, real, personal, or mixed, and any other article, commodity, or thing of value wherever situate, and shall include any trade or commerce directly or indirectly affecting the people of this state. (5) "Unfair methods of competition and unfair or deceptive acts or practices" means any one or more of the following: (A) Passing off goods or services as those of another; Antitrust Law SECTION 6-36-2 § 6-36-2 Purpose ­ Rules of construction. ­ (a) The purposes of this chapter are: (2) To promote the unhampered growth of commerce and industry throughout the state by prohibiting unreasonable restraints of trade and monopolistic practices, inasmuch as these have the effect of hampering, preventing, or decreasing competition. It is intended that as a result the prices of goods and services to consumers will be fairly determined by free market competition in activities affecting trade or commerce in this state, including the manufacturing, distribution, financing, and service sectors of the economy, except as otherwise provided by the statutes, regulations, and judicial decisions of this state. The general assembly intends to exercise fully its power to affect and regulate commerce in order to effectuate the purpose of this chapter. The insurers can do what they want currently in most states. In RI, their god. Hell, our local BC this summer won the right to contract for drugs solely with CVS (nations larges drug store with it's home right here in RI land) so that they could: give the prescription benefit for the HMO Medicare programe. Guess what, our general assembly were just made to look like fools as BC just announced their stopping the benefit. So feel free, anyone out there, to tell our DOH, our Dept of Business Regulations, or BC, UHP, Harvard Pilgram, Tuffs, Cigna, etc. that they can't do it. Yah, yah, yah, cash only, say it and they will come, if I think more of my self I'll get paid...etc, etc, etc. I'm not rolling over, I'm getting elected! Dan Becker, DC, DABCN ------------------- Date: Sat, 23 Oct 1999 08:56:19 -0700 From: Moses Jacob Subject: Re: [c] Only paid for Acute low back Sig, Let us explore what your is definition of "doing the right thing". You are expressing an "ethical" concept or right vs wrong here. UR is combination of peer review, professional self-policing, legal protection for the payers against abuse either by the provider or the patient. In a perfect world no doctor would over treat, every doctor would chart identically( or close to it),every patient would get better timely ( no matter what technique or Rx), no carrier would downcode. Ethical and professional treatment protocol were developed to assist us in doing things "right" as you state. For the majority of cases, dare I say 80-90% all goes well. The patient improves, the Dr did his/her job monies are exchanged according to contracts etc. It is the remaining 10 to 20% ( 20 may be too high) which creates a niche for UR and payor/provider dispute. Even in this group the patient may have a problem which falls off the standard parameters or to accepted guidelines. You have previously stated some of these are internal proprietary payor data. So how do we determine what is right when the Dr. is being ethical, the patient still has not recovered; the patient feels the care is necessary to all for less than normal activity of daily living, but someone cuts of care? meaning the cash flow is halted.The moral Dr can not ethically ( abandonment comes to mind) discharge the patient. Let us assume that other medical/PT care has also "failed". Who then becomes the "right" decision maker? I saw a case like that just this week.The lady worked as an electronic assembler. As she was trying to plug in a disc drive in her left arm she felt a sharp pain up her arm to her neck. Her employer said see your Dr. She went to her MD who suggested DC care. (yes there are some good MDs too). She picked a DC who started her on 3x/week.This continued for some 15 months. Her x-rays revealed DISH in the thoracic spine. The patient had prior Hx of migraines > 15 years. She had had Rx for Vicodin and started taking as many as 20 or more per day.No help. Her MR revealed mild T8 disc bulge. No herniation. They sent her to a pain management clinic.She had 3 or 4 sessions of 8 to 10 facet injections.No help either. Her Rx had to be changed due to liver enzyme problems from the Vicodin. She has tried PT no help. She gained 40 to 50 lbs now at 240 lbs. Her DC still treats her now once weekly. According to the patient it's the only thing which give her any relief although it very short-lived anywhere from hours to a few days. So this megillah leads me to ask is it ethical (right) for the DC to keep her coming? Is it ethical for me to cut her off? (I probably won't). Or on the "science" side I ask why is this lady still hurting. DISH in the thoracic spine usually doesn't follow this painful a course. As an aside her "migraines" started after her molars were removed 15 years ago. Her left TMD was the source of her chronic pain. At least head and neck wise. All those vicodin, before this current injury, were prescribed for the wrong diagnosis ( in my not so humble opinion). By the way she was also seen by a psych who felt she did not have any psych problems.All that pain is not in her head. So back to your posited point of doing the "right thing". How would you handle this type of situation under UR issues? Lets kick it around. Professionally yours, Moses --------------- From: "ChiroView" Subject: Re: [c] Only paid for Acute low back Date: Sat, 23 Oct 1999 07:29:54 -0700 Look...here's the deal. I realize that payers can do anything they want and UR companies can do anything they want..but it doesn't mean it's right or lawful. If I turn away and do nothing...then I am as wrong. I do what I think is right...and most of the time it's opening my "pie -hole" so those who are doing it can have the opportunity to do the right thing. I can tell you most doctors, when challenging the UR decision, win...just because most people rendering the UR decision are not equipped to argue. Many doctors that appeal with ChiroView win simply because they have now taken the time to write down on paper what they failed to do in their charting. Many times I set up a conference call between doctor, reviewer and patient. The patient often states their case far better than the doctor and the treatment is then authorized for reimbursement. For me it's not about winning or losing anymore...it's about doing the right thing, being heard while always trying to maintain a reasonable level of professionalism and respect. Cheers, Sigmund Miller, DC ------------------ From: spinedoc Subject: Re: [c] Only paid for Acute low back Date: Tue, 26 Oct 1999 21:30:07 -0000 Here in tenn. united healthcare has lowered its fee schedule to less than what medicare pays for adjustments. they have also lowered what they reimburse for any exams, modalities, etc for chiropractors. I spoke with the vice president about how the fee scheduled was determined (the letter said based on RVU values) and if they were across the board for all providers. He said that they have only reduced what they pay for these services if a chiropractor performs them. the podiatrists and optometrists also got there fee schedules cut also. His justification was that they pay every specialty different fee schedules, cardiologists are paid different amounts than orthopedists for the same code, and that they were confident the market would bear there changes. My question, is this illegal discrimination or do we accept this if we sign a PPO contract? Any thoughts? spinedoc -------------------- From: Backfixer@aol.com Date: Tue, 26 Oct 1999 21:38:29 EDT Subject: Re: [c] Only paid for Acute low back In a message dated 10/26/1999 6:29:30 PM Pacific Daylight Time, spinedoc@naxs.net writes: << Here in tenn. united healthcare has lowered its fee schedule to less than what medicare pays for adjustments. they have also lowered what they reimburse for any exams, modalities, etc for chiropractors. .... spinedoc >> Actually, United Health Care is in trouble and they are losing money. You are just a pawn in a poorly administrated health care company. Here in NJ, you cant even get on the panel and from what I have heard lately, Why would I want to. I suggest that all providers drop out, and you organize it. We had a problem with PCMC a couple of years back and I did this with two other docs. Their claims administrator could not defend the fact they were screwing us and undercapitating our network, paying us $6 one month, killing most of us. Be creative, however, it will only change if you do it as a group. No docs, no network. Make it look like it is not organized. This way, noone gets in trouble. By the way, Oxford lowered our fees a while ago to less than Medicare, They did it to prevent going out of business. They still pay us deascently and ask our opinions. Unfortunately, United needs to be handled more harshly. Organize and take no prisoners William Charschan D.C.,C.C.S.P. --------------- From: "Dr. Michael Massey" Subject: Re: [c] Only paid for Acute low back Date: Wed, 27 Oct 1999 10:41:00 -0400 I'm personally acutely aware of the situation in TN with UHC. I dropped them a line (via TCA) after the final fee schedule was sent out to let them know that the trade association that represents chiropractors found their offering to be unacceptable. What I received in turn was much the same dialogue that you did regarding the market, to the point they said, "there are starving chiropractors who would jump at those fees"... While we have run this all past our legal counsel, he has found nothing in the contract that keeps them from doing this to us since it is a contractual agreement, and if you don't like it you can leave the network. We have (through the PRN fax) advised everyone to notify both their UHC-covered patients and the local companies who have UHC of what's going on and the potential for a mass exodus of chiropractors, podiatrists, and optometrists. Likely, pressure from policyholders will go a longer way than pressure from providers. However, we are currently working with both the TPMA and the TOA to see if there's something we can do jointly to pressure them to change this policy. As a side note, they did NOT use the RBRVS as a determiner of those fees. I computed them myself and came out way higher than they did... They may have used the computed fees as a basis, then cut them by x%, but the fees they published are certainly not RBRVS-equivalent for Tennessee. Many of the doctors I've spoken to are finding it difficult to leave UHC due to the volume of patients they see with UHC coverage. I doubt if we'll ever get a full agreement on leaving the network en masse for that reason. However, I see nothing wrong with attemtping to organize such... I will keep all interested parties informed on the progress of this effort. Michael Massey, DC, CCSP ------------------- Date: Wed, 27 Oct 1999 13:18:02 -0400 From: daniel becker Subject: Re: [c] Only paid for Acute low back Actually both. The fees schedules are discriminatory based on free market access concepts. However, we don't have a free market and for some reason, the politico's don't seem to understand this. However, if you sign the contract, wellllllllllllllllll... You signed a contract. The big issue with providers is that there is no true "negotiations". As our lawyer worded it, the contracts that we sign are "contracts of adhessions" that is when there is no meeting of the minds do to the strength of one party. This is the legal concept that we must stress as the politicians believe that true negotiating is taking place. Dan Becker, DC, DABCN ----------------------