RE: Re: Insurance Reform

[Guest guest]

Jim, that was a terrific post.

And , I like your comments as well, although I find they are not practical.

Even though I believe we provide better service and outcomes than some other

local clinics, we can’t turn down most of the poorly paying contracts.

Because many of our patients are blue collar, they would flock to the other

practices that would be sure to accept any and all unfavorable contracts: the

POPTS and the corporate owned. Believe me, I’d love to see a revolution, but

every practice would have to participate.

Unfortunately, we have found that the minute patients have to pay out of pocket

for PT, they elect to self-discharge.

I agree that having National standards for all medical coverage, including those

companies who choose to self-fund would be beneficial.

Viel, Office Manager

Mt. Eden Physical Therapy Center

From: PTManager [mailto:PTManager ] On Behalf Of

dosrinc

Sent: Friday, February 12, 2010 9:56 AM

To: PTManager

Subject: Re: Insurance Reform

Great post Jim, I would like to comment on this portion

" For the most part, Insurance Reimbursement dictates whether you get paid and

how much. The patient comes in the door for your services, but the patient's

insurance company dictates what you have to do, whether you did it right and how

much you are going to get paid to treat that patient. Is this right or wrong? "

In my opinion, this is wrong, and until we get some federalization or other

standardization/transparency as to what an individual patient's insurance

contract allows I think it behooves us as a profession to take this power away

from the insurance company. We are the professional, we, in consultation with

the patient, and directed by our experience and the scientific evidence, should

be the ones dictating what it is that we do and how we do it. The marketplace

should determine how much we get paid for it. How do we accomplish this? We

refuse to contract with insurance companies, we do what we do and we make the

patient responsible for the payment. I think it is only when the providers

remove themselves from this battle with the insurance agencies that we see the

insured begin to revolt and demand better from the companies that they send so

much money to.

Sincerely,

E. s, PT, DPT

Orthopedic Clinical Specialist

Fellow American Academy of Orthopedic Manual Physical Therapists

www.douglasspt.com

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> All

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> With last week being Super Bowl weekend, imagine referees calling penalties

based upon football rules within their given state. Or worse, having to call

penalties based upon where the player’s out of season residence is. If a

player’s off season residence is California, the referee would have to

call penalties based upon California football rules. If the player resided in

Tennessee, then…, you get the picture. Can you imagine the nightmare and

headache involved in calling a game? With that analogy in mind…

>

> I have just spoken with a representative from one of my United States

Senator's office about Federalizing Insurance Laws. The conversation was

extremely generic, as this representative wasn't in tune with Healthcare

Providers and the issues they face. As we spoke, I used acronyms like CMS

(Center for Medicare/Medicaid Services), MAC (Medicare Administrative

Contractor), rs, Intermediaries, ERISA (Employee Retirement Income

Security Act of 1974), etc. When I finished, she was very candid and told me

that she wasn't well versed in what I was talking about. She did provide me with

a contact that is better positioned to discuss provider reimbursement issues and

I have left a message. I have been a proponent of federalizing insurance

regulations to " level the playing field " for providers. But I do not think I am

doing a good job of educating people why I believe this is important. I wish

every single person that reads PTManager would take some time to read this post.

For the most part, Insurance Reimbursement dictates whether you get paid and how

much. The patient comes in the door for your services, but the patient's

insurance company dictates what you have to do, whether you did it right and how

much you are going to get paid to treat that patient. Is this right or wrong? I

think there are as many opinions on this question as there are readers of

PTManager posts.

>

> Let me start out by stating that there are 4 Federal Programs establishing

laws governing the healthcare of the people that fall under these Federal

insurance programs (there may be more, but I don't have time to research). The 4

are as follows:

>

> 1. Medicare

> 2. Medicaid (Federally Funded program with State matching funds required)

> 3. Champus/Tricare (Insurance for Military Personnel and their families)

> 4. ERISA (Employee Retirement Income Security Act of 1974) I believe this

covers self funded insurance benefit plans. And here is a link if you would like

to read up on it:

>

> http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm

>

> In addition to the 4 Federal programs, each state has their own set of

insurance laws, governing insurance companies that operate within their state

boundaries. Each year, our Federal Regulations undergo some modifications. Each

year, our state insurance laws undergo modifications. Each year, our Insurance

Companies review their Medical Policies and modify them if they chose to.

>

> Let me first isolate the Medicare program (but I believe the same statements

that I am making for Medicare will probably hold true for the other 3 Federal

Programs..., if not, I am sure someone on this listserv will correct me).

Medicare has a printed medical policy and a series of printed geographic

reimbursements for their services (i.e., the Physician Fee Schedule). Everyone

has access to that policy, and if a provider doesn't understand the why of

something, can pull up this policy and review it. If they don't like something

in that policy, they can protest it, appeal it or accept it and move on/change

their treatment methodology. The same holds true for the other 3 federal

programs. However, I would expect that not everyone encounters the other 3

programs as much as they do Medicare.

>

> Now, if a patient comes through your door and has an insurance other than the

ones illustrated above, chances are that you are dealing with an insurance

company that falls under your state law's jurisdiction (unless this patient

resides out of state or was injured on the job in another state..., in which

case that state's laws govern your treatment). All of these insurance companies

have established Medical Policies. At this point I would ask all of you reading

this the following questions:

>

> 1. Does your state law formulate a standard for medical policy (and if they

don't, who decides medical policy for insurance companies/beneficiaries)?

> 2. If not, does your insurance company publish or otherwise make their medical

policy available to you?

> 3. How many medical policies should you have to know in order to provide the

appropriate medical treatment for your patient?

>

> In the past 2 decades, CMS (Center for Medicare/Medicaid Services) has been

undergoing a transformation. In the late 80's, HCFA (HealthCare Financing

Administration) had laws on the books that were being interpreted by multiple

Medicare rs (Medicare Part B-Outpatient Clinics) and Intermediaries

(Medicare Part A-Hospitals) in each state. In each state HCFA had at least one

r and Intermediary under contract to administer their regulations and

provide oversight of their programs. In some states, HCFA had multiple rs

and Intermediaries. Each r and Intermediary was responsible for

interpreting those regulations. In recent years we have seen consolidation of

rs and Intermediaries into MAC's. While I cannot pretend to understand

HCFA/CMS' decision for this consolidation, I suspect it had a basis in reducing

cost and providing more consistent interpretation of the regulations. I know the

WPS (Wisconsin Physician Services) is now the MAC for at least 8 states (4 of

which they handle both Medicare A and . The result of this consolidation has

been more consistent interpretation of the Medicare Regulations across both

Medicare A and B settings (Hospitals and Outpatient clinics respectively)

>

> Where am I going with all of this? Ask yourself these questions:

>

> 1. In addition to knowing the 4 Federal Programs Medical Policy, how many

other medical policies do I have to know within my state boundary?

> 2. Am I treating a patient that was injured in a Work Related Accident from

out of state? If so, do I know the W/C (work comp) Medical Policy for that

state?

> 3. Are any of my patients covered under an out of state policy? If so, what is

their medical policy?

> 4. ***MOST IMPORTANT*** Should Insurance medical policy coverage be

substantially different from one insurance company to the next or, could a

federal policy be generated that could govern 90% of what we do?

>

> These issues don't always affect the healthcare provider because they hire

staff to " handle " these issues. But the support staff can chew up a lot of

administrative time digging for answers to these questions. If they don't,

Insurance companies can typically tell patients that the provider knew or should

have known their policy before treatment started.

>

> I believe that if we could establish a single Medical Policy or even limit the

numbers of policies, it would save a great deal of healthcare provider time and

money (i.e., reduce expenses). Or, maybe an even better option (which employers

seem to be embracing more regularly), is to push patients over to a catastrophic

policy with a Medical Savings (health savings account) account. That way the

insurance companies have less control and the consumer becomes more responsible

for their healthcare decisions.

>

> If you have made it this far in the post, congratulations for not falling

asleep!!! Federalization of insurance laws may not be the answer, but some form

of standarization is. And I do not see 50 states binding together to come up

with a common set of laws or a common medical policy.

>

> Jim Hall, CPA <///><

> General Manager

> Rehab Management Services, LLC

> Cedar Rapids, IA

> 319/892-0142

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