Archive | March 2011

UHC: Extended Deadline for Premium Designation Program

This message is from the AMA who has worked with UHC at the national level:

UnitedHealthcare has extended the reconsideration deadline for Premium Designation Program (PDP) ratings:

  • Physicians now have until May 1 to submit reconsideration requests.
  • Physician designations will be publicly displayed on UnitedHealthcare’s consumer Web site on June 1.

Please refer to UnitedHealthcare’s information sheet for additional details about these changes.

UnitedHealthcare delayed the reconsideration deadline and public display of PDP results following physician feedback indicating that UnitedHealthcare’s group affiliation information was inaccurate or incomplete. UnitedHealthcare has corrected group affiliation data, and some physicians’ PDP ratings may have changed as a result of these updates. UnitedHealthcare guarantees that all reconsideration requests that are submitted by May 1 will be processed prior to the public display of Premium designations on June 1. UnitedHealthcare will be sending letters to physicians whose group affiliation status has changed.

The AMA appreciates UnitedHealthcare’s improved communication regarding the PDP and responsiveness to physician feedback. These positive changes show the value of the collaboration between UnitedHealthcare and organized medicine’s Physician Profiling Workgroup over the past few years. This spirit of cooperation will serve the workgroup well as it addresses other physician profiling concerns, such as attribution rules, reliability testing and lack of transparency with respect to misclassification rates. The AMA looks forward to continuing this work with UnitedHealthcare to improve physician data systems and the quality of care.

HORIZON: Compliance Dispute Ruling Affects Non-Par Plan Reimbursement

The national class-action settlement dispute officer (CDO) recently dismissed two compliance disputes filed by MSNJ members under the national class-action settlement agreement. The CDO’s decision has negative ramifications for physicians who participate in Horizon’s PPO plan under contracts that incorporate by reference certain payment policies in the Horizon PPO Office Manual. The CDO’s decision allows Horizon to reimburse for services to patients in non-contracted plans at the contracted PPO rate, instead of UCR, and allows Horizon to prohibit balance billing of these patients.

The physicians participated in Horizon’s traditional PPO plan, but chose not to participate in Horizon’s other managed care plans. Both practices anticipated receiving reimbursement at usual, customary and reasonable rates (UCR), the benchmark for out-of-network fees, and for which there is a settlement term on fee methodology. Instead, Horizon reimbursed some fees at the contracted traditional PPO rate when the physicians treated Horizon patients in other plans. While the rate of reimbursement was higher than those of the non-contracted plans, it was lower than what would be expected based on UCR.

Horizon also took the position that the practices were prohibited from balance billing under the terms of the PPO Contract and Office Manual. The practices and MSNJ believed that Horizon’s actions, not paying UCR for non-contracted plans and prohibiting balance billing, violated the national BCBS class-action settlement agreement. MSNJ supported the practices’ compliance disputes; the national class-action settlement facilitator found the disputes valid and prosecuted them before the CDO.

The CDO decided that the PPO contract required the physicians to accept Horizon’s contracted rates and to forego balance billing when they treat Horizon’s managed care members. His decision was based on contract law and his conclusion that Horizon effectively made the Manual a part of the contract.

The CDO also considered “participating” and “non-participating” status under the settlement agreement and found that these terms could be interpreted to allow Horizon to treat physicians with only a PPO contract as “participating” physicians as to Horizon. Consequently, the rights of non-participating physicians under the settlement agreement simply did not apply to physicians in this situation.

Last, the CDO determined that the “all-products clause,” designed to limit the power of insurers who contract with one plan to contract with all plans, was not available to the physicians. He noted that the physicians were not required to contract with all plans, or required to accept the contracted rates for those plans. In his view, physicians are not compelled to treat Horizon patients in plans in which they do not participate. However, once physicians treat patients in non-contracted plans, the contract and any payment policies incorporated by reference, may limit reimbursement.

MSNJ is disappointed with the result in this case. While physicians may not be compelled to treat all Horizon members, the economic reality in New Jersey is that Horizon is the state’s dominant healthcare insurer. Many physicians have no meaningful participation choice, beyond their ability to pick and choose among plans. If contracting with one Horizon plan means that physicians who treat Horizon patients in other plans—out-of-network—will receive the discounted rate, then it is imperative that physicians carefully consider whether it is economically feasible to treat Horizon’s members out-of-network.

Comprehensive Medical Liability Reform Legislation Advances

A1982, a bill addressing comprehensive medical liability reform passed the Assembly Health Committee today with the support of five Democrats and three Republicans.  There were two abstentions, Asw. Nancy Munoz (R – Union) and Asm. Jerry Green (D – Union).

The move marks the most progress on comprehensive tort reform in over six years.  The measure is now pending on the Assembly floor for a vote by the full House.  MSNJ thanks sponsor Asm. Herb Conaway, MD (D – Burlington) and will work with him to see that this momentum continues.

Breaking News! Assembly Health Committee Schedules Tort Reform Vote

The Assembly Health and Senior Services Committee has scheduled a vote on comprehensive medical liability reform legislation this Monday, March 7 at 10:00 am. The committee will be voting on A-1982, which includes new requirements for expert witnesses, modifications to the statute of limitations, requirements for affidavits, and a prohibition on premium increases for claims that do not succeed or arise out of charitable or emergency care.

A favorable vote by the Committee on Monday will mark the most progress made on tort reform in over 6 years.  MSNJ members are encouraged to call or write their legislators, or come to the proceedings and show your support for this important legislation. For a complete listing of committee members, click here.