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01/11/2014 Billie A. Bondar, DPM
Have you recently been dropped from an insurance network?
I am writing again...to say that the stress and frustration that one goes through when dealing with network termination is not to be taken lightly. I had voiced my words negatively at APMA when indeed they were on board for me with a letter of support.
Let me note that I was heading for a second appeal to this network with an attorney per PICA to find that the networks medical director had sent a rejection letter to me for the first appeal accidentally pushing a wrong key on his computer . I won the appeal and did not need to get an attorney. My credentials, my integrity, my clean record, my training, and my board certification choice were of strong standing in the end per letters of orgs, myself, and many docs to help me fight.
So to others in the mess please do not give up. Fight the fight for you livelihood if you care for this profession .. I do still want to be a podiatrist. I am proud to be a podiatrist. I do know that we have way to much external stuff to deal with that is taking away from the care of peoples extremities.
I have EMR layers now and ahead to deal with them put some ICD-10 to address soon in there, and add a double patient schedule this year. I did not keep up with what is going on out in the real world of medicine for such subjects as networks , ACA, manuals, etc. I know many of you are in the same boat sadly lagging behind in reading and investigating and searching for the info needed because your doing podiatry the act of treating patients!
So I apologize to AMPA-- you have a website full of info (that I honestly sat down and looked at last night) and I am so glad you reviewed it in the response for others to seek ...do it my fellow pods ..take the time and get your user/password out again to wander in the website! If troubles develop in an administrative issue, seek PICA as this company is behind you members as I found out.
But the most important thing to convey .. believe in yourself .. do not let your inner self get beaten down ... all the years of practicing podiatry for thousands of patients counts for a real standing when the challenge occurs. Be strong and get help with your orgs and your peers! We have a lot of negative stuff ahead to deal with and I wonder will society have a PA do footcare vs a podiatrist in a few decades .. perhaps. But we are the specialty that are the best trained and practiced now to give citizens of America stellar podiatric attention. Do not forget that please.
Billie A. Bondar, DPM, Rochester, NH, hrcbillie@aol.com
Other messages in this thread:
01/29/2014 Ed Davis, DPM
Have you recently been dropped from an insurance network? (Carl Solomon, DPM)
Dr. Solomon recently made the following comments: "Even if we know our negotiated fee, in many instances we aren't even allowed to collect it. I pose the question: "In what other business is it required that instant credit be extended to all customers, and with terms that are undefined and difficult to enforce?" He is correct in that health care providers are extending credit to patients for services rendered. That is the insurance game known as "time value of money" in which there is a monetary value to the time period from the delivery of a good or service to the time of payment. The only reasonable tools we have to mitigate the loss is to collect deductibles and co-pays up front at the time of service. Perhaps a percentage of the total need be added beyond those items in anticipation of non-payment or improperly reduced payments by third parties which is commonplace. Insurance companies often improperly bundle services/charges then state that the patient is not responsible for the balance.
I realize that I am opening a can of worms here but if a third-party adjudicates a claim improperly then there is a breach of contract that occurred such that third-party may be improperly telling us to write off what should not be written off. Certainly, one should appeal such improper claim adjudications but that is labor intensive and adds time to payment, thus financial loss to the practitioner. We have lost a significant amount of control over the third-party reimbursement system but the one thing we can do as a profession is to establish reasonable standards as to how claims are to be adjudicated, including which services are separately payable. That can be done on the national or state level via a committee formed.
It is insanity to allow third-parties to make such determinations. Imagine any supplier who provides a product being told by the purchaser that for every dozen widgets provided we will pay as follows: 100% for the first widget, 50% for the second, then 20% for the third, the fourth is incidental to the third and cannot be separately billed and so on. Ed Davis, DPM, San Antonio, TX, ed@sanantoniodoc.net
01/23/2014 Sloan Gordon, DPM
Have you recently been dropped from an insurance network?
I offer a standing ovation to Dr. Sasiene and Dr. Garoufalis with respect to their letter and their 'campaign'. Having just read the NY Times article this weekend about how "egregious it is" for doctors to make money from ancillary services, turned my stomach. Oh those RICH doctors.
The article described how a dermatologist doing Moh's surgery had to take the patient to the OR for a plastic closure and graft of their face. Not a word about thank goodness my cancer was cured, but the BILLING for $1000 for anesthesia, $1800 for the center and of course the doctor billed $800. Can you imagine what they will all NET? Perhaps $500/800/400.
What other profession takes a negotiated rate? Lawyers, senators, CEOs of insurance companies ... seriously? How does insurance have such a great lobby? I hear Aetna's CEO makes $40 MILLION dollars a year. How many lives does he save, oh, he does save them money by not paying the people who really do the work and save the lives: physicians.
Medicine is on the way out. I had my flu shot from an NP in Walgreen's because my doctor said it cost too much to have the vaccine in his office! My families' GP retired and an NP took over the office. My surgical assistants are PAs and many are paid well over six figures. My last PA, who bills for a group, thanked me and showed me a check stub for $6000.00 for assisting me with an ankle scope + OATS procedure. He was so embarrassed ... think of how I felt?
We, as a profession, including DOs, DPMs, MDs, and all physicians will continue to 'take it' as long as we continue to yield to the insurance companies edicts. My auto mechanic does not accept negotiated rates; BP, Texaco, Exxon, Shell do not accept negotiated rates. Why are we the only patsies who do? Our society has been deceived into thinking we're just replaceable parts who can fix them. And when we can't, because we can't get the equipment or the care they need (refused by an insurance adjuster) we get sued.
Many docs I know feel dentistry had the right idea: stick together, do not take insurance and do not yield. That's why I pay $1,800 for a crown and $45 for a tooth x-ray while I get $750 to replace a 1st MTP joint and $30 for a foot x-ray!
Something is seriously wrong. The old timers sit back thanking God they are at the tail end; the millenniums accept it and the bulk of us just shake our heads and keep moving forward for doing what is right and just caring for the patients. But, it's time someone woke up! Let the government have Obamacare but let every politician from the President on down have the same insurance as the general public.
Sloan Gordon, DPM, Houston, TX, sgordondoc@sbcglobal.net
01/20/2014 Jack Sasiene, DPM
Have you recently been dropped from an insurance network? (Matthew Garoufalis, DPM)
First, let me thank Dr. Garoufalis for responding in this forum. I hope all of you reading out there take the time to let him know how you really feel. One can not do a good job leading unless they get input from the members. Just grumbling and following does nothing. I think after reading the string of comments on this and many other impediments to practice, that doctors, not just podiatrists, are fed up with the business of medicine. The issue is not podiatry here but the fact that we can’t be, for the most part, doctors. Between ICD-10, meaningful use, and now the attestation audits, insurance plans thinning its providers to limit patient utilization, and us being contract labor, we’ve all just about had enough. To all this, Dr. Garoufalis states the following: “APMA has been diligent in sharing information with members about provider terminations, narrowing of provider networks, and managed care contracting through its various communication vehicles, including APMA News, APMA.org, APMA Weekly Focus, and APMA News Brief.” and “Because the vast majority of members’ concerns have been focused on Medicare Advantage Organizations’ termination of provider contracts, APMA has created a wealth of resources on that topic.” It is obvious from the results that the above has not resulted in effective action by the APMA. Telling us that all this is happening, how to manage those situations and sending letters, at the very least is thoughtful, but it obviously is not helping the bottom line for those in full time practice. Take the current issue of ICD-10. We are told by “leaders” in our profession after doing everything right, the insurance industry may not crosswalk the codes correctly and payments will be delayed…….having to hold onto patient premiums for awhile. No conflict of interest there. What would the retail industry do if credit card processors said they were changing the processing of charges and it might result in a 6 month delay in payment. I think they might tell them to get it right before instituting it or they won’t take credit cards. We are told: to put aside up to 6 months of overhead! That would be about $240K for me...really?
There is a disconnect here between those of us working on patients for a living and those leading us. Those who want a one payor system for simplicity are on to something…..it should be the patient!
The only way doctors will get back control of their practices is to work for themselves, not insurance companies whose only concern is money. It is not about making a ton of money but doing more than staying a float and paying our employees.
The APMA AND AMA with a powerful lobby, need to act in an interest consistent with doctors being able to provide the best care for their patients. Take that bold step Mr President and inform your colleagues how best to take control of their practices, not how to continue to work within a system that is failing. We will still need the APMA for many other issues after we aren't working for the insurance companies. Jack Sasiene, DPM, Texas City, TX, Sasiene@aol.com
01/11/2014 Bryan Markinson, DPM
Have you recently been dropped from an insurance network?
I am confused. Let me start by saying I have the utmost respect for Drs. Garoufoulis and Guiliana. They are doers and elevate our profession in their daily work. Dr. Garoufalis states that we have been warned that the ACA would result in commercial carriers shrinking their networks, yet APMA went to bat for Dr. Bondar with Multiplan. The results of that meeting was that, "APMA has been warning of this."
I would like to know exactly why the networks are shrinking. Does it cost money to keep a provider electronically in a data base? Is it a credentialing issue? Is it a control issue? Do we really want to be included in these plans? What became of Dr. Bondar's case? And how can this be an individual podiatrist issue? Can this happen to an iron worker or bricklayer? Where is the GUILD?
How could the mass dropping of DPMs from plans not be a universal issue that demands explanation as to why networks are shrinking in preparation for millions more insured? When APMA meets with the carriers, what are we being told? Podiatrists are not the only providers going through this. Connecticut primary care physicians have filed suit and received an injunction against the dropping of providers. Is APMA on that? Are we following it closely or waiting to see the results in the newspaper? Can we learn something from the goings on in that case?
Dr. Guiliana touts PICA's administrative insurance which may protect/assist providers being unjustly dropped from the plans. Do we assume that the ACA law gives justification to drop providers from plans? The "letters" he is referring to do not at all challenge anyone's integrity, they just tell you that you are out. Is that indeed "unjust?" Does the state insurance department also protect me from this to some degree?
Is Dr. Guiliana inviting all PICA insured podiatrists that have been dropped from plans to start using their administrative insurance coverage and demand action? Again, shouldn't that be a mass undertaking and not just individual?
OR, is the real lack of mass outrage simply due to a wait and see what happens attitude? Do we perhaps not want to unknowingly lock ourselves into contracts that certainly will be worse than what we now have?
I am confused. Aren't you?
Bryan Markinson, DPM, NY, NY, bryan.markinson@mountsinai.org
01/10/2014 Matthew Garoufalis, DPM
Have you recently been dropped from an insurance network? (Billie Bondar, DPM)
APMA recognizes Dr. Bondar’s frustration at being terminated from the Multiplan network; however, APMA takes umbrage with Dr. Bondar’s comments that the association has not been educating its members. In fact, APMA has been diligent in sharing information with members about provider terminations, narrowing of provider networks, and managed care contracting through its various communication vehicles, including APMA News, APMA.org, APMA Weekly Focus, and APMA News Brief. APMA contacted Multiplan in support of Dr. Bondar when she first reported the issue in November and requested a meeting with the company’s medical director to discuss a variety of issues with Multiplan. Recently, in response to the Affordable Care Act and other legislative and regulatory actions, private insurance companies, including commercial and Medicare Advantage plans, are narrowing their provider networks and terminating physicians, including podiatrists, from their plans. Because the vast majority of members’ concerns have been focused on Medicare Advantage Organizations’ termination of provider contracts, APMA has created a wealth of resources on that topic. We encourage members to review the following information on this subject: June 28, 2012 APMA News Brief Physicians Need New Approach to Managed Care Contracts July/August 2013 APMA Website Medicare Advantage Termination FAQs Sample Patient Letter and Communicating with Patients About Termination from a Medicare Advantage Plan August 19, 2013 Weekly Focus New Medicare Advantage Educational Materials Available Online October 2013 APMA News Termination of Medicare Advantage Organization Provider Contracts November 8, 2013 CAC/PIAC 2013 Presentation Emerging Issues in Private Insurance Video on Health-care Reform (Preview) Video on Market Trend Video on Medicare Advantage (Preview) November 27, 2013 APMA News Brief ‘Narrow Networks’ Trigger Push-Back From State Officials December 18, 2013 APMA Letter to CMS on Medicare Advantage Termination In addition to the information detailed above, APMA and state Carrier Advisory Committee (CAC) representatives and Private Insurance Advisory Committee (PIAC) representatives keep each other abreast of payers’ actions to narrow their networks so we may effectively assist members. Members are always encouraged to contact CAC/PIAC representatives. To find your representative visit www.apma.org/CACPIAC. Moreover, APMA continues to advocate for APMA members and their patients. Most recently, APMA has written to CMS and Multiplan, and several weeks ago, APMA spoke with representatives from UnitedHealthcare. APMA continues its education effort through its Reimbursement Webinar Series. The first webinar of this year, “Affordable Care Act (ACA) in Action, Sustainable Growth Rate (SGR) Repeal, and Physician Payment Outlook for 2014,” will be held on Thursday, January 16, from 8–9 p.m. EST. APMA members may sign up for this complimentary Webinar at www.apma.org/webinars. Also, the Private Insurance Resource Guide at www.apma.org/PIRG provides a wealth of materials to help members with their contracting issues. Finally, APMA members are welcome to contact APMA with questions or comments at healthpolicy.hpp@apma.org.
Matthew Garoufalis, DPM, President, APMA, mggaroufalis@apma.org
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