Just ask any husband who has ever forgotten one, and he'll tell you, anniversaries are a time to remember. This past weekend marked the eighth anniversary of the announcement of a class action lawsuit brought against managed care companies by the Medical Society of the State of New York (MSSNY). In a coordinated effort, suits were launched at that time not only by MSSNY, but also by 17 other states and counties against six major insurers including Excellus, Aetna, Cigna and United.
“We just got tired of all the improper business practices of all the different insurance companies and a lot of states were getting like this, and we all knew we needed to do what we could to fight back against them,” says Dr. William Dolan, one of the primary plaintiff's in the MSSNY suit, former MSSNY President and current trustee of the American Medical Association (AMA).
Some of the improper practices outlined in the suit include: arbitrarily reducing a physician's payment for medically necessary care by "downcoding," or changing claims and billing codes to indicate a doctor should be paid less; bundling claims, or issuing a single payment for a group of related medical services; failing to pay physicians in a timely fashion; forcing physicians and their staffs to expend an unreasonable amount of time and resources attempting to obtain reimbursement to which they are entitled; exploiting the doctors' unequal bargaining power to force physicians to enter into one-sided HMO contracts.
Excellus was the first company to settle, and in the end, all but United Health followed suit. The settlements included both monetary payment and agreement to improve practices. For example, the Excellus $60 million settlement included a payment of $1500 to all of the physicians in the involved upstate NY counties as well as agreement to completely adhere to the CPT4 Codes, Guidelines and Conventions, which they had not previously been following.
In recounting the day the suit against Excellus was announced eight years ago, Dr. Dolan recalled the beautiful view of the New York cityscape, including the then still standing Twin Towers. And while the skyline of the city, and indeed our nation have undoubtedly changed since then, the battle between physicians and the bad practices of insurers has remained constant.
Just this past spring New York Attorney General Andrew Cuomo filed suit against United Health and Ingenix Inc., for allegedly altering data so insurers paid less and patients more for out-of-network services. “It's fraud. They deliberately cut the numbers so the consumer pays more of the cost,” Senator Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee told The Associated Press of the practice.
“There's a lot of excess money being spent on the part of practitioners on billing the insurance companies,” Dolan says. In 2008, the AMA launched the National Health Insurers Report Card (NHIRC), which evaluates major insurers on 13 metrics regarding the timeliness, transparency and accuracy of claims processing. With physicians spending close to 14 percent of their income on billing, it's clear that steps such as this and more are still necessary. A PNC bank study estimated that $200 billion are spent each year on billing.
“We're going to have to continue stridently, and to do battle if necessary or come to some negotiation with AHIP [America's Health Insurance Plans] and the various insurance companies with all our information, and they know, in the past, we've won these battles,” Dolan said.
As we move forward in the healthcare debate, it is important to remember and remain mindful of these past, present and future battles between physicians and insurers, as we won't be able to make up for forgetting them with flowers or expensive jewelry.
“We just got tired of all the improper business practices of all the different insurance companies and a lot of states were getting like this, and we all knew we needed to do what we could to fight back against them,” says Dr. William Dolan, one of the primary plaintiff's in the MSSNY suit, former MSSNY President and current trustee of the American Medical Association (AMA).
Some of the improper practices outlined in the suit include: arbitrarily reducing a physician's payment for medically necessary care by "downcoding," or changing claims and billing codes to indicate a doctor should be paid less; bundling claims, or issuing a single payment for a group of related medical services; failing to pay physicians in a timely fashion; forcing physicians and their staffs to expend an unreasonable amount of time and resources attempting to obtain reimbursement to which they are entitled; exploiting the doctors' unequal bargaining power to force physicians to enter into one-sided HMO contracts.
Excellus was the first company to settle, and in the end, all but United Health followed suit. The settlements included both monetary payment and agreement to improve practices. For example, the Excellus $60 million settlement included a payment of $1500 to all of the physicians in the involved upstate NY counties as well as agreement to completely adhere to the CPT4 Codes, Guidelines and Conventions, which they had not previously been following.
In recounting the day the suit against Excellus was announced eight years ago, Dr. Dolan recalled the beautiful view of the New York cityscape, including the then still standing Twin Towers. And while the skyline of the city, and indeed our nation have undoubtedly changed since then, the battle between physicians and the bad practices of insurers has remained constant.
Just this past spring New York Attorney General Andrew Cuomo filed suit against United Health and Ingenix Inc., for allegedly altering data so insurers paid less and patients more for out-of-network services. “It's fraud. They deliberately cut the numbers so the consumer pays more of the cost,” Senator Jay Rockefeller, chairman of the Senate Commerce, Science and Transportation Committee told The Associated Press of the practice.
“There's a lot of excess money being spent on the part of practitioners on billing the insurance companies,” Dolan says. In 2008, the AMA launched the National Health Insurers Report Card (NHIRC), which evaluates major insurers on 13 metrics regarding the timeliness, transparency and accuracy of claims processing. With physicians spending close to 14 percent of their income on billing, it's clear that steps such as this and more are still necessary. A PNC bank study estimated that $200 billion are spent each year on billing.
“We're going to have to continue stridently, and to do battle if necessary or come to some negotiation with AHIP [America's Health Insurance Plans] and the various insurance companies with all our information, and they know, in the past, we've won these battles,” Dolan said.
As we move forward in the healthcare debate, it is important to remember and remain mindful of these past, present and future battles between physicians and insurers, as we won't be able to make up for forgetting them with flowers or expensive jewelry.
'all the improper business practices'
ReplyDeleteyou know, i was a class rep. i remember the buzz at the time when dr dolan announced the lawsuits at the mssny house of delegates.
i'm not sure we've seen the end of all the improper business practices. that'd be among the most welcome outcomes of the healthcare reform debate.
cr
And the incompetence of NGS?
ReplyDeleteFrom: MSSNY General Counsel’s Response to Insurance Industry Report
ReplyDelete'I think we all need to be reminded that the New York State Attorney General's investigation into the use of the Ingenix database by health insurers to determine reimbursement rates, and the Staff Report for Chairman Rockefeller, Committee on Commerce, Science, and Transportation, Office of Oversight and Investigations, June 24, 2009, illustrate that we must all be a little skeptical when reviewing reports issued by the health insurance industry concerning health care charges.
It is unclear why payer entities warrant further protection since they already garner special treatment afforded no physician.
ReplyDeleteThese include special antitrust treatment, special treatment under ERISA, supplemental funding under Medicare Advantage,
and state insurance departments that set insurance company rates in a manner to assure a company profit.
Only stakeholders that add value going forward should be
part of the solution.
NY State has an aggressive Insurance Department except when it comes to Health Insurance. It's time to change this.
ReplyDelete