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ACP-ASIM's continuing campaign to reduce the "hassle factor"

From the forthcoming May 2000 ACP-ASIM Observer, copyright 2000 by the American College of Physicians-American Society of Internal Medicine.

By Robert B. Doherty

Fact Sheet

Ask internists what bothers them the most, and the answer usually has something to do with the hassles of dealing with Medicare and managed care. Pre-authorization requirements, downcoding, delays in getting claims paid, retroactive denials and excessive documentation--the litany of hassles that drives internists mad goes on and on.

The hassle factor was a major topic of discussion at last month's Board of Governors meeting. Many Governors said that the College was doing an impressive job of tackling the "hassle factor," but they also worried that very few members realize what we are doing.

The College's approach

ACP-ASIM devotes a very large share of its resources to reducing physician hassles. In July of 1998, the College formed the Medical Services Committee and charged it with "improving payment, coverage, coding, documentation and medical review policies that are adopted by third-party payers, both public and private, that act as barriers to the provision of high-quality and cost-effective care to patients."

Two additional bodies--the Managed Care and Third Party Relations Subcommittee and the Coding and Payment Subcommittee--share the workload and report directly to the Medical Services Committee. (It is a sign of how bad the hassle factor is that it takes three College committees to address the problem!)

ACP-ASIM's Division of Managed Care and Regulatory Affairs provides staff support to these three bodies, providing four staff experts with extensive experience in managed care, coding, coverage, quality assurance, medical review and payment policies.

The physicians who serve on the Medical Services Committee and its related subcommittees don't just issue reports and hope that something good happens. Rather, they believe in tackling issues head-on with the individuals who make decisions. At every committee meeting, they talk to top officials from HCFA and managed care organizations. They grill them on objectionable policies and advocate for alternatives.

Between meetings, the members who work on these bodies spend hours discussing the latest regulatory developments via e-mail until they reach a consensus. They know all too well that many urgent issues can't wait until the next face-to-face meeting. It then falls to the Washington staff to lobby HCFA and health plans to bring about the needed changes.

Staff from ACP-ASIM meet frequently with officials from HCFA and the Office of Inspector General (OIG) to discuss internists' concerns about Medicare payment policies and fraud and abuse enforcement. College representatives have been invited to meet with policy-making groups from the Blue Cross and Blue Shield Association, the Health Insurance Association of America and the American Association of Health Plans, all of whom have stated that they are committed to working with us to reduce hassles affecting physicians.

Our role in other organizations

The College also brings about change through its representation in organizations that have direct influence over third-party payment policies. ACP-ASIM is a parent member of the Joint Commission on the Accreditation of Health Care Organizations (JCAHO) and the Utilization Review Accreditation Commission (URAC). While the URAC is less known than the JCAHO or the National Committee on Quality Assurance, it accredits utilization management companies and preferred provider organizations. The URAC's standards affect more "covered lives" than any other accrediting body.

The URAC recently agreed to develop standards on claims administration and processing, as requested by ACP-ASIM, to address concerns about delays in paying physicians. The URAC is expected to establish a standard that would require accredited plans to pay "clean" claims within clearly defined time frames. If the URAC establishes the standard, it could help move the entire industry to pay physician claims more promptly.

ACP-ASIM is also represented on both the Current Procedural Termionology (CPT) Editorial Panel and the CPT advisory panel. By adding or revising CPT codes, we can influence payers to reimburse for services that otherwise might go unpaid.

The College also has a representative on the Relative Value Update Committee (RUC), a multispecialty committee that is chaired by the AMA. The RUC provides recommendations to HCFA on how to value the physician work that is associated with each service in the Medicare fee schedule. Because HCFA accepts more than 90% of the RUC's recommendations, the College's involvement gives internists an important vehicle to influence Medicare payment policies.

In addition, ACP-ASIM was one of three physician organizations represented on a laboratory negotiated rule making committee established to develop standardized Medicare policies for 23 clinical laboratory tests. We had two goals: to reduce the administrative burden that physicians face when ordering laboratory tests and to replace arbitrary local carrier policies with standardized rules. In March, HCFA published a proposed rule for comment based on the committee's recommendations.

Finally, the Practicing Physicians Advisory Council (PPAC), a congressionally-mandated committee that advises HCFA on payment and coverage policies, is chaired by Derrick L. Latos, FACP, a former College Governor for the West Virginia Chapter. ACP-ASIM has provided regular advice and testimony to the commission on the hassles that affect internists.

Having internist-members on the right committees at the right times--with support from the College--is an essential part of our advocacy program. Being at the table doesn't mean that we'll get everything we want. It is a lot better, though, than not being there at all.

Results

Do the College's efforts make a difference? ACP-ASIM recently distributed a fact sheet to the Board of Governors that listed 36 specific actions the College has taken that have helped reduce hassles affecting internists (A copy of the fact sheet is attached).

Examples include persuading Medicare to allow separate payment for colorectal screening services furnished on the same day as an office visit or consult; blocking mandatory hospitalist programs in three states; eliminating offensive language in the OIG's "Who Pays, You Pay" anti-fraud campaign; and persuading one of the insurance industry trade associations to recommend that all member-plans use a single credentialing form.

Despite our successes, internists still face far too many hassles. It is in the nature of insurance companies and government agencies to try to limit how much they'll pay, using whatever methods are available, no matter how many problems it causes physicians and patients.

ACP-ASIM will not allow such practices to go unchallenged. You can help us identify practices by Medicare, managed care plans and other payers that are making you and your staff waste valuable time--time that you could better spend caring for patients. We can't promise to liberate you from all of the paperwork imposed by Medicare and managed care plans, but we will try to make things better.

Robert B. Doherty is ACP-ASIM's Senior Vice President for Governmental Affairs and Public Policy.

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