As
1999 drew to a close, federal lawmakers enjoyed a holiday leaving many health
care issues on “bed rest” until January 24th when the second session
of the 106th Congress returns from recess.
Patient
protection, medical records privacy, and medical errors will be but a few of
the policy issues reopened for debate.
The Senate Committee on Health, Education, Labor and Pensions will begin
a series of hearings on Tuesday, January 25th focusing on the
findings and recommendations of the Institute of Medicine’s recently released
report on medical errors.
Addressing
the issue of uninsured Americans, President Clinton announced that he will ask
Congress for an additional $2.7 billion to make it easier to enroll eligible
children in the federal program, Children’s Health Insurance Program. With nearly 44 million Americans uninsured,
this issue will remain a topic of national debate. Clinton’s budget proposal for 2001 is expected to include a request
for $168 billion over 10 years to expand Medicaid and provide tax credits and
incentive to companies to help cover health care insurance costs.
The
close of the year also means “numbers” – and lots of them. The Health Care Financing Administration
released figures showing that US health care spending rose 5.6 percent to $1.1
trillion dollars in 1998, the biggest jump since 1993. Follow the money to rising drug and
insurance premium costs. Prescription
drugs grew more than any other category, a little over 15 percent. Insurance premiums more than doubled the
increases in recent years rising 8 percent.
In
other year-end reports, business headlines indicated that for-profit HMOs are
expected to post solid fourth quarter earnings in spite of recent pressure from
lawsuits and concerns about government price controls. Financial analysts see managed care
companies taking advantage of premiums rising faster than medical costs in the
context of a stronger US economy, industry consolidation that has reduced
competition in certain markets, and an uptrend in the industry’s pricing
cycle. It will, no doubt, be an
interesting year.
The Editor
Managed Care
Implements “Red Carpet Access Line”
A new service has been implemented to assist callers from outside the medical center with managed care administrative issues. Primarily for providers and health plan representatives, this “one point of access” service can handle a request or connect the caller with the appropriate person or department.
Questions regarding eligibility, selection of a PCP, out-of-area transfers and admissions, claims, and other administrative or operational issues can be expedited for the caller who is unfamiliar with Medical Center operations.
The
Managed Care Red Carpet Access Line, at 312.996.4374, can handle administrative
issues Monday through Friday, 8:00 a.m. until 5:00 p.m. Calls concerning “out-of-area” patient
transfers or admissions can be handled 24 hours a day, seven days per week.
You
and members of your staff comprise the Medical Center’s management response
team. With your commitment, calls
received by the help line can be resolved while the caller is on the line or
with a prompt return phone call if additional information is required. If
contacted by the service, it means that a customer is on the line and waiting
for a response!
The
institutional goal is to meet the needs of our patients and other “customers”
quickly and efficiently. We are
committed to providing answers and resolving problems concerning managed care
issues. Your support and assistance are essential to the success of this
program. Together we can make
University of Illinois Medical Center a more responsive partner.
(The
help line is not intended to replace the working relationships that currently
exist between UIC staff members. Please
continue to call members of the managed care staff directly – as you normally
would – for the assistance you need.)
Effective
January 1, 2000, all claims for United Healthcare, including claims for
“capitated” services should be filed directly with the plan. Submit claims for United Healthcare Select,
HMO, Medicare Complete, Chicago HMO Medicaid & United Health One to PO Box
169087, Duluth, MN, 55816. Submit
claims for United Healthcare Open Access to PO Box 169056, Route 2942, Duluth,
MN, 55816. All other United Healthcare
products have the claims address listed on the back of the member’s
identification card. Please update your files to reflect these changes.
Please be aware that United Healthcare of Illinois Medical Management Department’s phone has changed to 1-888-541-8504. This phone number can be used for the following products: HMO, Select, Medicare and Medicaid, Select/Premier Network, Select Plus and Open Access. Only their PPO products have different numbers that vary by group. Those numbers can be found on the back of the members ID card.
Vision Care Benefits – A Reminder
Most
health plans provide members with vision benefits through a designated network
of providers. Our capitated commercial contractors – American Health Care, UnitedHealth
Care, Humana, and HMO Illinois – are no different. Each plan has a specific
provider for their members.
UIC primary care physicians should NOT refer members to our
ophthalmologists for routine eye exams or refractions. Please advise members to follow instructions
from their health plans to obtain these services. Their benefits administrator
or customer service representative can assist them.
UIC primary care physicians can refer members to our
service at the Eye and Ear Infirmary when there is eye disease or injury.
If the member elects to go to EEI for services, they should be told that
their insurance may not cover the visit and they will receive a bill for
services.
One of “medical district” neighbors, Union
Health Services, provides medical care to employees of several local
unions. They are interested in using
UIC providers for specialty services for nearly 30,000 covered lives. A letter of agreement has recently been
signed allowing UHS patients to begin receiving services immediately. We are very excited about this opportunity
with Union Health, whose main office is located on Polk Street between Ashland
Avenue and Paulina Avenue.
As of January 1, 2000, BCBSI has contracted with American Specialty Health Network to provide their HMO members with access to a discount complementary medicine program called “Blue Extras.” BCBSI has recognized the popularity of these services and will help members obtain alternative treatments such as chiropractic, massage, and acupuncture services from this network of providers.
Chiropractic care is a covered benefit for HMO members and a referral from the PCP is needed in order for the patient to receive these services as a covered benefit. Members may also seek chiropractic services without a referral from their PCP but at their own expense.
No referral is needed for HMO members to take advantage of other alternative medicine services such as acupuncture or massage therapy. They are not covered benefits under this plan. Members will receive a discounted rate, which is usually 25 percent off billed charges.
HMO
members can call the toll-free number access line at 1.800.892.2803 or go
online at www.Healthyroads.com for
information about the alternative medicine provider network directory.
As a growing number of Americans seek alternative care, managed care organizations and insurance companies have become more receptive about offering and covering these services. Americans now spend an estimated $25 million annually on non-traditional therapies including acupuncture, homeopathy, massage, and chiropractic services. Managed care and insurance companies have taken notice. So have a number of state legislatures, which have begun to mandate coverage for some alternative treatments.
In
Washington State, a law requiring health insurance companies to cover
alternative medical services such as chiropractic care and massage therapy is
back in effect after withstanding several legal challenges from the insurance
industry. Under their
every-category-of-provider law, health plans cannot exclude any category of
professional licensed to provide care for a condition that is covered by the
plan. Members can choose between
providers in different categories (an internist or acupuncturist for back
problems) when both are licensed to treat the condition.
In
a recent industry survey, chiropractic is the most commonly offered type of
alternative care followed by acupuncture and massage therapy. Industry executives and analysts expect
consumer demand to raise. While the
validity of alternative medicine is growing in the medical community, hard data
establishing links to health status and improvement as well as cost benefit
will need to be collected.
Plans
provide alternative medicine benefits as part of their “core” programs similar
to traditional treatments, offer optional coverage for an increased fee, or
offer referrals to alternative providers who agree to discount their fees. Oxford Health Plans, Aetna U.S. Healthcare,
and BlueCross BlueShield are among the companies that offer such discount
plans.
State of Illinois
Passes Legislation of Interest to Provider Groups
The December newsletter profiled the Illinois Patient Bill of
Rights. Also passed at the end of the
1999 summer session were several other public acts including PA91-0605, known
as the Prompt Payment Act, and PA91-0602, the Health Care Professional
Credentialing Act. Both should be of
interest to our readers.
As of January 1, 2000, the Prompt Pay Act requires that insurance
and managed care companies pay claims in a more timely fashion. In general, features of the bill require
that:
¨ Clean claims
must be paid within 30 days of receipt of the claim. Beginning in 2001, this will also include certain claims paid by
IPAs and PHAs.
¨ HMOs must make
timely capitation payments. Initial cap payments to the physician must occur
within 60 days of the effective date and subsequent payments must be made
monthly.
¨ Interest of 9
percent will be paid on late claims.
Payment of interest will be automatic; providers will not have to bill
insurance or managed care companies to collect.
The caveat here is that the insurance company will determine when
a claim is “clean”. However, they must
inform the provider and the insureds within 30 days if a claim is not
considered “clean”. Practice
administrators and billing managers should check with their billing service to
ensure that this provision is being met.
Referred to as the “credentialing simplification” act, the Health
Care Professional Credentials Data Collection Act seeks to streamline the
credentialing process. With input from
physician and industry representatives, the Department of Public Health will
develop forms that will be implemented in the coming months. Highlights of the
act require that:
¨ All health plans
to use standardized forms beginning July 1, 2000 for credentialing and
recredentialing providers.
¨ Recredentialing
will occur only once every two years unless quality assurance concerns require
more frequent review.
¨ Credentialing
decision be made within 60 days of receipt of information.
¨ All credentials
data will be collected once and used by all plans (effective July 2001).
¨ All health plans
will use a uniform site survey instrument (effective July 2001).
¨ All health plans
that require a site visit must coordinate a single site visit to cover all
plans; the single site visit will occur only once every two years (effective
July 2001).
The passage of this act should provide some relief to providers
and department staff; a standardized data collection form will allow
departments to create a form template and credentialing “database” for each
provider.
A new year and a new opportunity - to improve on our commitment to provide you with information about managed care and related health industry news. In response to comments from readers, we plan to present some basic information about managed care in upcoming issues. If you’re not sure what it’s all about, you’re not alone. EPOs, FMCs, HMOs, PROs, IPAs, MSOs, UROs - in this acronym intensive industry, perhaps we can help.
For those of you would like additional information on any of the topics included in the newsletter, please contact me at mgm@uic.edu. We’ve got web sites, source documents and other reference information.
Mary Gibson, Editor
The
Managed Care Department, University of Illinois at Chicago, College of
Medicine, presents Managed Care
News online. Comments or requests should be addressed to the editor at mgm@uic.edu.