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

Other messages in this thread:

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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

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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

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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