American College of Physicians: Internal Medicine — Doctors for Adults ®

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Policy briefs

From the June ACP Observer, copyright 2003 by the American College of Physicians.

Medicare must now explain some denials to patients

Under a new Medicare policy, beneficiaries who receive a notice that a claim is denied based upon a local medical review will now be able to talk to someone from their third-party carrier about the decision.

Medicare summary notices, the monthly statements sent to beneficiaries, will identify denied services and claims made by a local medical review board. They will also give patients a telephone number to get more information about the decision.

A Medicare customer service representative must be available to explain these decisions, provide copies of the denial form and tell patients how to file an appeal.

This change is the result of continued efforts by ACP and other organizations to ensure that Medicare communicates directly with beneficiaries about denials or restrictions that will increase patients' out-of-pocket costs.

Medicare has also agreed to remove the phrase "not medically necessary" from beneficiaries' summary notices when a service or claim is denied. ACP has complained that the language was inflammatory and encouraged beneficiaries to distrust their physicians.

The College hopes that an explanation of why a service has been denied will help patients understand the Medicare coverage decision process. ACP also hopes the new service will help patients understand that Medicare carriers limit their coverage to certain conditions. More information is online.

OIG warns physicians about joint ventures

The HHS Office of Inspector General (OIG) issued an advisory warning physicians about joint venture business arrangements that reward them for improper patient referrals and violate the federal anti-kickback statute.

The bulletin focuses on joint venture arrangements that disguise illegal kickbacks through a combination of "shell" entities and subcontracting arrangements with providers of health services such as durable medical equipment.

The OIG warned that it is illegal for physicians to enter into an arrangement when:

  • The physician expands into a related business that is dependent on patient referrals from an existing business.

  • The physician does not operate the business or commit substantial resources to it.

  • A physician contracting with the business would be a competitor if a written arrangement were not in place.

  • Payments to physicians are based on their referrals to the new business.

The OIG bulletin is online.

Problems with health plans? ACP wants to know

If you are having payment or administrative problems with a health plan, ACP wants you to report it online.

The College has teamed up with the AMA to track problems physicians encounter in their day-to-day interaction with health plans. The form is online.

By tracking and documenting these trends, ACP is working to eliminate the hassles that many internists say they experience when dealing with national health insurers. The College can also use this information to promote legislative and regulatory changes to help internists and their patients.

In 2001, ACP introduced a resolution in the AMA House of Delegates that called for a complaint form. The reporting process is now up and running, allowing both organizations to compile information in one simple format that protects the privacy of physicians and their patients.

You can complete the easy-to-use form online, or you can print it and complete it on paper. To use the form, you'll need your medical education number.

College urges N.J. insurer to stop bundling, downcoding

The College has joined three other professional organizations to demand that a New Jersey insurer stop inappropriately denying claims. The group said that Horizon Blue Cross Blue Shield of New Jersey is not following coding rules established by Current Procedural Terminology (CPT).

The March 28 letter, which was signed by ACP, the AMA, the American Osteopathic Association and the New Jersey Medical Association, gave several examples of ways that Horizon has misinterpreted CPT:

  • denying additional services provided on the same day as a separate evaluation and management service (identified by modifier -25);

  • downcoding office visits and consultations submitted as level 5 to level 4 (99215 downcoded to 99214, or 99245 downcoded to 99244); and

  • bundling CPT codes 98925-98929 for osteopathic manipulative treatment with appropriately performed, documented and reported evaluation and management services.

The letter noted that CPT contains specific instructions on the scope of each of the above codes and modifiers, and that these guidelines do not support Horizon's interpretation of CPT codes. The letter also reminded the insurer that Blue Cross Blue Shield was represented on the editorial panel that created the CPT coding system.

The organizations urged Horizon to adopt the appropriate uniform use of CPT codes, guidelines and conventions.

The letter to Horizon is online.

ACP protests insurer's move against gastroenterologists who work in hospitals

ACP and the American Gastroenterological Association (AGA) have expressed strong concerns about a health plan that is "deselecting" gastroenterologists who perform most of their upper endoscopies and colonoscopies in hospital settings.

Empire Blue Cross Blue Shield in New York recently notified physicians that it prefers to work with gastroenterologists who can perform upper endoscopies and colonoscopies in outpatient settings like ambulatory surgery centers and community-based offices.

In a Feb. 26 letter, ACP and the AGA noted that physicians may not have access to all of the "preferred" settings and requested additional information on the deselection process. The letter also expressed concern that arbitrary decisions made about the location of services like colonoscopies could harm patient care.

The joint letter to Empire is available online.

Better communication from Medicare carriers is coming soon

In response to pressure from ACP and other provider organizations, Medicare carriers are preparing to roll out new initiatives to educate and communicate with providers.

The Centers for Medicare and Medicaid Services (CMS) has told its carriers to expand their educational and training services to meet physicians' basic information needs and to train physicians new to the Medicare program. Carriers will soon have to offer a Web site for providers that contains bulletins and newsletters, schedules of upcoming seminars and workshops, downloadable training materials and information about electronic claims submission.

The CMS is also requiring carriers to create at least one electronic mailing list they can use to notify providers about time-sensitive information.

Carriers must also support and maintain an advisory group to oversee educational efforts and to disseminate information to providers. Each advisory group will include physicians from various specialties, as well as representatives from state and local professional organizations.

These advisory groups must meet three times a year to guide the development and implementation of physician education efforts.

More information is available online from the "Medicare Carriers Manual."

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