Re: Insurance Reform

February 11, 2010

Hey Jim,

Excellent post. kept me awake all the way through. If enough of us post

to our elected reps and senators maybe somebody will reinforce the idea

that the bills currently being proposed do NOT cover areas that need to be

addressed.

A. Towne, PT

In a message dated 2/11/2010 2:01:31 P.M. Eastern Standard Time,

JHall49629@... writes:

All

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 playerâ€™s out of season residence is. If

a playerâ€™s off season residence is California, the referee would have to

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

Tennessee, thenâ€¦, you get the picture. Can you imagine the nightmare and

headache involved in calling a game? With that analogy in mindâ€¦

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.http://wwhttp://www.dhttp://www.dol.http_

(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/beneficia1. Doe

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

[Non-text portions of this message have been removed]

February 11, 2010

Jim -

Here is a tool you might find helpful to send to your Senator - " If Air Travel

Worked Like Healthcare " (

). The video

is based on an article by Rauch in the National Journal.

Enjoy,

Todd

Todd Gifford PT

TherapeuticAssociates

www.therapeuticassociates.com

www.careconnections.com

phoneÂ |Â ext 1102

Insurance Reform

All

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 playerâ€™s out of season residence is. If a

playerâ€™s off season residence is California, the referee would have to call

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

Tennessee, thenâ€¦, you get the picture. Can you imagine the nightmare and

headache involved in calling a game? With that analogy in mindâ€¦

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

February 11, 2010