A Message from the
Director……
I
am sure most of you have seen the latest provider directories issued by the
health plans and available at the benefit fair. I am also sure that most of you
are concerned and disappointed over the obvious errors and omissions found in
each of the health plans' directories.
I would like to explain the process of how the health plans compile and
publish their provider information, the sources of many of the errors, and what
our department is doing to address these issues.
Most
health plans maintain a database of contracted providers from which they
extract information in order to print their provider directories. This information is obtained through the
credentialing process. At UIC, the
Medical Staff Office gathers provider information from each department,
verifies the information (credentials each provider), then submits it to health
plans. The information is either
submitted directly to the plans by the Medical Staff office or to the Managed
Care office that subsequently forwards it on to the health plan. All physicians must complete our internal
credentialing process before any information is supplied to the health
plans. Our credentialing process can take
up to 90 days but in most cases is completed within 60 days. Before the health plans publish physician's
information in their directory, they must be assured the credentialing process
is complete. An alternate method is
performed by some health plans (such as Aetna); they conduct their own
credentialing process. This lengthens
the process to variable degrees.
Currently, Aetna's process consumes the longest period of time and can
take anywhere from 90 to 270 days.
Note that the credentialing process is also a requirement for NCQA
accreditation and therefore the process is tightly controlled and frequently
audited – there are no shortcuts or "special favors".
Once
a month the Managed Care office receives updated credentialing information from
the Medical Staff Office (i.e. new entries, deletions, and changes). We then conduct our own review, which
includes soliciting assistance from each department. Physicians who don’t see managed care patients do not need to be
credentialed by the health plans nor should they be included in the health plan
directories. The Managed Care office
has omitted these names from the provider lists sent to health plans. Both the Medical Staff office and the
Managed Care office have now established policies and procedures to keep this
listing up to date with the appropriating coding for those physicians who do
not serve managed care patients.
Our
office provides the health plans with the most current provider information,
including changes to previous lists, on a regular basis. We have also asked the health plans to
provide us with feedback and pre-published listings so we can review them for
changes prior to printing of their directories. To date, HMOI is the only plan who has given us this opportunity
and unfortunately they do so over three months prior to publication rendering
the information that is printed somewhat outdated. Fully recognizing that there are often strict cut-off dates for
editing and printing of provider directories, we still believe there is an opportunity
for the Managed Care office to have an impact on this process. We believe we can achieve a better outcome
by dedicating a full-time employee to work directly with each contracted health
plan on an on-going basis. Managed Care
is in the process of hiring a person to accomplish this difficult task.
Managed
Care will also be instituting other changes to assist in overcoming some of the
obstacles we currently face with provider directories. Coming soon through the managed care web
page will be:
·
A
link to the health plans to verify information for each provider and department
to verify their own information and status
·
A
list showing physicians' credential status with each contracted health plan
We
want you to know that we clearly recognize the importance of incorrect and
incomplete publishing of UICPG provider information and that we intend to
intensify our efforts to hold each contracted health plan accountable for
updated provider information.
Let
me make one more note to address another concern. Most health plans service claims by tax ID number. Because we all use the same tax ID number
most claims will not be denied because they are from a provider not currently
listed in a provider directory or fully credentialed by a health plan. Should you receive an Explanation of
Benefit (EOB) from any contracted
health plan that reflects a denial of services because the physician is
not credentialed a copy of the EOB should be sent to our Managed Care Provider
Service Representative Barbara Rabin (M/C972). Barbara is our contact with each health plan and can help
resolve these issues. Thank you.
Roger Carlson, Director of Managed Care
American Health Care
Providers, Inc. Declared Insolvent
The
Illinois Department of Insurance (DOI) has been successful in its efforts to
demonstrate the insolvency of American Health Care Providers (AHCP) effective
May 11, 2000. The Illinois Health
Maintenance Organization Guaranty Association (IHMOGA) has been activated to
protect enrollees of AHCP. The IHMOGA helps provide some financial protection
in cases such as AHCP through "Assessments" levied against other
Illinois HMOs.
As
of May 1, 2000 AHCP still had 32,000 commercial enrollees. Many of these enrollees are our own
employees who selected AHCP as their option during last year's enrollment
process. IHMOGA has agreed to
reimburse UIC for covered services May 11, 2000 and thereafter at the same
contracted rate AHCP was provided.
Because
it is unclear which AHCP enrollees are still eligible for services, eligibility
should be verified at each encounter by calling AHCP at 708-503-5000. All
specialty referrals should have a completed and signed Referral Form by the
assigned PCP or payment could be denied.
These patients should be registered under financial class J19 (American Health Care HMO), JB3 (American Health Care HMO-UIC) or JAA (Department of Psychiatry).
Routing of claims involving these financial classes remains the same. Any questions regarding benefits or covered services can best be addressed by calling AHCP directly at 708-503-5000.
IQ
Health has been selected to provide real-time, on-line access to various health
plans to confirm eligibility. The
vendor contract is currently being finalized.
Over the next few weeks, departments will be contacted to develop a user list. Members of an implementation group will work with each department to ensure a smooth introduction of this software.
Details about the applications and project status reports will be made regularly in the newsletter. Questions about this project can be directed to Ron Plemmon at rplemmon@uic.edu or at X3.8541.
Preferred Plan, Inc.
Contract Amendments
In
recent months there have been several amendments to the contract with Preferred
Plan, Inc. These include:
Preferred
Plan recently developed an EPO (Exclusive Provider Organization), which has a
hospital network that is a smaller subset of the larger PPO network of
hospitals. The EPO has approximated
2,500 lives in the area. UIC Medical Center is now part of their EPO
network. A new J-Code is being
established for this business and the new contracted rates will be in the
hospital contract grid, which is distributed by the Managed Care Operations
office on a regular basis.
Preferred
Plan also changed the Payment Methodology for physician services. It’s now 85% of charges or 140% RBRVS for
Cook County, which ever is lesser and any CPT code without a RBRVS dollar
amount will be reimbursed at 85% of charges.
Anesthesiology will be reimbursed
$38 for each 15-minute unit.
There
is also a language amendment for both the Medical Center and the Physicians
Group contracts which specifies that Preferred Plan is prohibited from leasing,
selling or allowing the use of the negotiated rates in our agreement to any
entity who is not a payor and directly contracted client of Preferred Plan,
Inc. This means no other PPO, broker,
network or other entity is allowed to access these contracted rates.
Effective
immediately, CVS Pro Care will be the preferred vendor for the administration
and distribution of self-injectable and specialty medications for all United
Health Care of Illinois enrollees.
To
place an order, CVS can be reached by phone at 1.877.287.1234 or by fax at
1.877.287.7226. All medications can be
shipped the next day to the physician’s home or the patient’s home, office or
vacation destination.
If
you would like a copy of the medication listing, please contact Jacqueline
Petersen, japeter@uic.edu.
Effective
March 1, 2000, the cardiac package coding has been updated by United Health
Care to reflect current coding.
Providers need to use current coding to ensure accurate claims
payment. To obtain a copy, please
contact japeter@uic.edu.
Still
sending paper claims to United Health Care of Illinois? United’s EDI System is available through
WebMD Practice. The WebMD Practice
system offers secure access to United at no cost. WebMD Practice also connects you to over 600 other payers for
electronic claims submission. If you
would like more information, please contact japeter@uic.edu.
MaxiHealth –Managed Health Service
MaxiHealth/MHS,
who administers the Indiana Medicaid HMO, has recently changed their address
for claims. As of April 17, 2000 the new address is Managed Health Services
Insurance Corp, Claims Department, PO Box 63640-3001, Farmington, Missouri,
63640. Please update your records.
Elsewhere in the News……
Wisconsin
joins more than a dozen states that now provide patients with independent
review of coverage decisions.
Legislation signed last Friday will create review boards that can order
health maintenance organizations and other insurers to pay for treatment that
the companies initially deny to patients. Wisconsin’s new law is more
comprehensive than similar measures in other states because it applies to all
commercial health insurance, not just HMOs.
The review panels will include specialists and will have 30 days to make
decisions about appeals put before it.
Last
Thursday the Illinois Supreme Court ruled that health maintenance organizations
can be held liable for direct corporate negligence involving medical care. Making local and national headlines, this is
the high court’s second major decision against HMOs in the last year, which
have fought moves to make them responsible for the medical decisions of
physicians who work under the HMOs’ names.
In September, the court ruled that HMOs can be held vicariously liable
for the medical malpractice of their independent-contractor physicians under both
the doctrines of apparent authority and implied authority. Apparent authority means that the HMO held
the doctor out as its employee and implied authority means the HMO exercised
some degree of control over the doctor’s medical judgment.
Thursday’s
decision means that HMOs can also be held liable under the theory of
institutional or direct corporate negligence.
The court concluded that because HMOs undertake an expansive role in
arranging for and providing health care services to their members, they have a
corresponding corporate duty to assume responsibility for their patients’
care. While the ruling does not apply
to enrollees of self-insured plans, it opens the way for patients to proceed
directly against HMOs for carelessness or negligence causing injury. Health policy analysts were quick to comment
that this latest decision adds to the momentum driving changes in how health
maintenance organizations do business.
And
while decisions are being made at the state level, House and Senate leaders
continue to struggle with various versions of a “patient’s bill of rights,”
which would, for the first time, establish comprehensive federal standards for
private health insurance including managed care. After almost seven months of wrangling, 17 of the 22 issues on
the table remain in dispute. Among the
unresolved are two hot-button issues – you guessed them – should patients be
allowed to sue or obtain independent reviews of their providers’
decisions. With the political climate
heating up, President Clinton met with congressional committee members pushing
for a break in the negotiations. With
less than 50 legislative days remaining in the 106th Congress,
lawmakers pledged to finish a compromise bill that will give new protections to
patients and expands access to health coverage for the uninsured.
The
Columbia/HCA Healthcare Corporation, the nation’s largest health care company,
has agreed in principle to pay $745 million in civil penalties to settle part
of a government inquiry into whether or not it cheated federal health programs. If approved, the settlement will be the
largest health care fraud settlement ever obtained by the Justice Department.
At the heart of the case was whether Columbia hospitals fraudulently overstated
their expenses to increase reimbursement from Medicare and other federal health
programs and engaged in illegal financial relationships with physicians. Allegations involved the practice of
upcoding and bundling unnecessary services in order to increase reimbursements. The announcement served as a denouement for
former company officials who were seen as visionary industry reformers
structuring a company that held itself out as a model in the increasingly
cost-conscious business of health care.
Criminal and other civil investigations into some of the company’s
business practices remain unresolved.
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.