Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 This conversation is now getting down to the nitty-gritty, which is, of course, all about pricing. Pricing is the magic language of commerce that occurs between consumers and producers/providers---the tangible picture of the intangible relationship between what consumers want and what producers/providers are selling. Political forces have caused certain of our economic economic sectors to be insulated from meaningful pricing. Medical care is probably at the top of that list (education and the mortgage market are two other current hot spots). The true cost of medical care has been clouded by mandates, incentives, tax rules, and government and private third-party participants. Each of those forces stand squarely between the patient and the provider, interfering, or completely controlling, that most delicate and important relationship. When we complain that we can't get paid for this or that, we are really complaining that someone other than the patient is acting as the customer. Government bureaucrats, or rule-makers, or corporate lackeys---each represents a false “customer” of sorts, and is therefore determining value in the true customer's stead. It is extremely frustrating for providers to deal with value-determiners who have no personal interest in the transaction, but that is all providers will ever get as long as our payment systems clog the patient/provider communication arteries. The only way to fix the mess is to allow the patient to once again become the customer. Support unencumbered health care savings accounts. Support real, honest, patient/provider communication. Dave Milano, PT, Rehabilitation Director Laurel Health System ________________________________________ From: PTManager [PTManager ] On Behalf Of jonmarkpleasant [jsppleasant@...] Sent: Saturday, February 13, 2010 6:15 PM To: PTManager Subject: Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Jon, I think we are splitting hairs here but if not then we agree to disagree. Of course cost is a factor, it is in everything a consumer wants to purchase but it is not the kind of factor that would limit therapy as much as you state. Again, as an example, there are plenty of thriving cash only PT practices. These would not survive otherwise. Also when it comes to total cost of a treatment upon discharge, if the therapist is treating according appropriate guidelines, the total cost for most treatments shouldn’t be that high, except in rare cases. In this area our perceived value has been seriously harmed by the preponderance of fraud and overutilization that continues to happen, running up huge bills on clients. In reality, most total PT bills are less than the cost of many medical procedures and some imaging studies as well. We use this comparison to help clients new to PT to understand cost. I still believe that people are questioning the cost and concerned about the cost of PT mainly because of the inability to see the value. In my clinic, even when explaining the reason for the frequency and duration of a treatment using research evidence (and we do not do 3X a week as a standard – we treat as needed from 1 session period to 5 X per week in cases that need it) we still often run in to those who cannot see the value of PT. Yet if these clients are being seen for a spinal diagnosis, many have a history of long term and repeated chiropractic visits, even when the effects of chiropractic are short term with no long term resolution of the problem. It is simply because they perceive that the chiropractors offer the best value for back pain and they are willing to pay for it. I am not advocating for the end to health insurance (although it would make a great protest statement to have all providers or clients in a state or region stop accepting it in order to bargain for better rates). What we do agree on is that our profession still needs to improve the perceived value of our services. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of jonmarkpleasant Sent: Saturday, February 13, 2010 4:16 PM To: PTManager Subject: Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Jon, I think we are splitting hairs here but if not then we agree to disagree. Of course cost is a factor, it is in everything a consumer wants to purchase but it is not the kind of factor that would limit therapy as much as you state. Again, as an example, there are plenty of thriving cash only PT practices. These would not survive otherwise. Also when it comes to total cost of a treatment upon discharge, if the therapist is treating according appropriate guidelines, the total cost for most treatments shouldn’t be that high, except in rare cases. In this area our perceived value has been seriously harmed by the preponderance of fraud and overutilization that continues to happen, running up huge bills on clients. In reality, most total PT bills are less than the cost of many medical procedures and some imaging studies as well. We use this comparison to help clients new to PT to understand cost. I still believe that people are questioning the cost and concerned about the cost of PT mainly because of the inability to see the value. In my clinic, even when explaining the reason for the frequency and duration of a treatment using research evidence (and we do not do 3X a week as a standard – we treat as needed from 1 session period to 5 X per week in cases that need it) we still often run in to those who cannot see the value of PT. Yet if these clients are being seen for a spinal diagnosis, many have a history of long term and repeated chiropractic visits, even when the effects of chiropractic are short term with no long term resolution of the problem. It is simply because they perceive that the chiropractors offer the best value for back pain and they are willing to pay for it. I am not advocating for the end to health insurance (although it would make a great protest statement to have all providers or clients in a state or region stop accepting it in order to bargain for better rates). What we do agree on is that our profession still needs to improve the perceived value of our services. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of jonmarkpleasant Sent: Saturday, February 13, 2010 4:16 PM To: PTManager Subject: Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Jon, I think we are splitting hairs here but if not then we agree to disagree. Of course cost is a factor, it is in everything a consumer wants to purchase but it is not the kind of factor that would limit therapy as much as you state. Again, as an example, there are plenty of thriving cash only PT practices. These would not survive otherwise. Also when it comes to total cost of a treatment upon discharge, if the therapist is treating according appropriate guidelines, the total cost for most treatments shouldn’t be that high, except in rare cases. In this area our perceived value has been seriously harmed by the preponderance of fraud and overutilization that continues to happen, running up huge bills on clients. In reality, most total PT bills are less than the cost of many medical procedures and some imaging studies as well. We use this comparison to help clients new to PT to understand cost. I still believe that people are questioning the cost and concerned about the cost of PT mainly because of the inability to see the value. In my clinic, even when explaining the reason for the frequency and duration of a treatment using research evidence (and we do not do 3X a week as a standard – we treat as needed from 1 session period to 5 X per week in cases that need it) we still often run in to those who cannot see the value of PT. Yet if these clients are being seen for a spinal diagnosis, many have a history of long term and repeated chiropractic visits, even when the effects of chiropractic are short term with no long term resolution of the problem. It is simply because they perceive that the chiropractors offer the best value for back pain and they are willing to pay for it. I am not advocating for the end to health insurance (although it would make a great protest statement to have all providers or clients in a state or region stop accepting it in order to bargain for better rates). What we do agree on is that our profession still needs to improve the perceived value of our services. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of jonmarkpleasant Sent: Saturday, February 13, 2010 4:16 PM To: PTManager Subject: Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Tom, We also partner with the patient in effort to tailor a frequency and duration that we feel is in their best interest while at the same time considering their financial concerns. This whole conversation brings up some very interesting " What ifs? " I would like to know everyone's thoughts about a world without insurance coverage for PT services. What would we as a profession do differently if we were not shackled with insurance regulations and contractual agreements? What would the practice of PT look like? 1. Would we single/double/triple book our patients because were no longer held to a contractual agreement? Insurance would no longer define how we book our patients. 2. Would patients stand for being double/triple booked if they were pay-for-service? 3. Would we no longer be required to use the CPT codes since the business transaction no longer involved insurance companies? 4. Would we be governed differently? 5. Would we treat without referrals? 6. How would this change our relationships with doctors? 7. Would we see more POPT competition since the MD's would longer be shackled by the Stark Laws? I'm assuming this simply because a self-referral to their PT services would no longer be a conflict of interest since it no longer involved an insurance company. 8. Would we resort to some of the current and past Chiropractic advertisement huckstering in order to survive? 9. Would PT no longer exist in the hospital setting if it were no longer billable through insurance? 10. Would our wound care services immediately evaporate and transfer to nursing? These are just a few questions. (I apologize since I didn't actually spend much time thinking about this.) I'm sure there would be some unexpected consequences if insurance no longer was in the picture. Some of the consequences could be good and some bad. However, in the end, a good business would adapt and change with the times. It's a deep but very interesting scenario. I've got to get off this computer and go work on my tax return now. HEY! There is another thread for Jim Hall, CPA to start. What if we went to a flat tax? Just kidding Jim. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Tom, We also partner with the patient in effort to tailor a frequency and duration that we feel is in their best interest while at the same time considering their financial concerns. This whole conversation brings up some very interesting " What ifs? " I would like to know everyone's thoughts about a world without insurance coverage for PT services. What would we as a profession do differently if we were not shackled with insurance regulations and contractual agreements? What would the practice of PT look like? 1. Would we single/double/triple book our patients because were no longer held to a contractual agreement? Insurance would no longer define how we book our patients. 2. Would patients stand for being double/triple booked if they were pay-for-service? 3. Would we no longer be required to use the CPT codes since the business transaction no longer involved insurance companies? 4. Would we be governed differently? 5. Would we treat without referrals? 6. How would this change our relationships with doctors? 7. Would we see more POPT competition since the MD's would longer be shackled by the Stark Laws? I'm assuming this simply because a self-referral to their PT services would no longer be a conflict of interest since it no longer involved an insurance company. 8. Would we resort to some of the current and past Chiropractic advertisement huckstering in order to survive? 9. Would PT no longer exist in the hospital setting if it were no longer billable through insurance? 10. Would our wound care services immediately evaporate and transfer to nursing? These are just a few questions. (I apologize since I didn't actually spend much time thinking about this.) I'm sure there would be some unexpected consequences if insurance no longer was in the picture. Some of the consequences could be good and some bad. However, in the end, a good business would adapt and change with the times. It's a deep but very interesting scenario. I've got to get off this computer and go work on my tax return now. HEY! There is another thread for Jim Hall, CPA to start. What if we went to a flat tax? Just kidding Jim. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Tom, We also partner with the patient in effort to tailor a frequency and duration that we feel is in their best interest while at the same time considering their financial concerns. This whole conversation brings up some very interesting " What ifs? " I would like to know everyone's thoughts about a world without insurance coverage for PT services. What would we as a profession do differently if we were not shackled with insurance regulations and contractual agreements? What would the practice of PT look like? 1. Would we single/double/triple book our patients because were no longer held to a contractual agreement? Insurance would no longer define how we book our patients. 2. Would patients stand for being double/triple booked if they were pay-for-service? 3. Would we no longer be required to use the CPT codes since the business transaction no longer involved insurance companies? 4. Would we be governed differently? 5. Would we treat without referrals? 6. How would this change our relationships with doctors? 7. Would we see more POPT competition since the MD's would longer be shackled by the Stark Laws? I'm assuming this simply because a self-referral to their PT services would no longer be a conflict of interest since it no longer involved an insurance company. 8. Would we resort to some of the current and past Chiropractic advertisement huckstering in order to survive? 9. Would PT no longer exist in the hospital setting if it were no longer billable through insurance? 10. Would our wound care services immediately evaporate and transfer to nursing? These are just a few questions. (I apologize since I didn't actually spend much time thinking about this.) I'm sure there would be some unexpected consequences if insurance no longer was in the picture. Some of the consequences could be good and some bad. However, in the end, a good business would adapt and change with the times. It's a deep but very interesting scenario. I've got to get off this computer and go work on my tax return now. HEY! There is another thread for Jim Hall, CPA to start. What if we went to a flat tax? Just kidding Jim. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Dave, Thanks for those insightful comments. As much as I agree with you, unfortunately I cannot foresee us completely and successfully removing the " false customer " from the relationship and directly engaging with the " true customer " with the system functioning as is. The American public has become too addicted to various entitlement systems, whether it's full coverage (i.e. non-catastrophic) insurance, Social Security, Medicare/Medicaid, growing numbers of government jobs with total compensation packages now greater than the private sector, etc., to voluntarily give them up without considerable systemic degradation or collapse forcibly thrusting the situation upon us. Human history has shown that the most significant societal learning and change only occur when preceded by a degree of suffering which, in turn, serves to raise public awareness and thereby spur remedial or reformative action. The article below states the dilemma we face more clearly and concisely than anything I've read in the mainstream media (which for the most part, is useless except for keeping track of celebrities, scandals, sports, entertainment, and the filtered and controlled news serving The Powers That Be and their Management of Perspective Economics). http://canadafreepress.com/index.php/article/19918 , PT, OCS Marquette, MI Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. > > > <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> > > > 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Dave, Thanks for those insightful comments. As much as I agree with you, unfortunately I cannot foresee us completely and successfully removing the " false customer " from the relationship and directly engaging with the " true customer " with the system functioning as is. The American public has become too addicted to various entitlement systems, whether it's full coverage (i.e. non-catastrophic) insurance, Social Security, Medicare/Medicaid, growing numbers of government jobs with total compensation packages now greater than the private sector, etc., to voluntarily give them up without considerable systemic degradation or collapse forcibly thrusting the situation upon us. Human history has shown that the most significant societal learning and change only occur when preceded by a degree of suffering which, in turn, serves to raise public awareness and thereby spur remedial or reformative action. The article below states the dilemma we face more clearly and concisely than anything I've read in the mainstream media (which for the most part, is useless except for keeping track of celebrities, scandals, sports, entertainment, and the filtered and controlled news serving The Powers That Be and their Management of Perspective Economics). http://canadafreepress.com/index.php/article/19918 , PT, OCS Marquette, MI Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. > > > <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> > > > 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi Dave, Thanks for those insightful comments. As much as I agree with you, unfortunately I cannot foresee us completely and successfully removing the " false customer " from the relationship and directly engaging with the " true customer " with the system functioning as is. The American public has become too addicted to various entitlement systems, whether it's full coverage (i.e. non-catastrophic) insurance, Social Security, Medicare/Medicaid, growing numbers of government jobs with total compensation packages now greater than the private sector, etc., to voluntarily give them up without considerable systemic degradation or collapse forcibly thrusting the situation upon us. Human history has shown that the most significant societal learning and change only occur when preceded by a degree of suffering which, in turn, serves to raise public awareness and thereby spur remedial or reformative action. The article below states the dilemma we face more clearly and concisely than anything I've read in the mainstream media (which for the most part, is useless except for keeping track of celebrities, scandals, sports, entertainment, and the filtered and controlled news serving The Powers That Be and their Management of Perspective Economics). http://canadafreepress.com/index.php/article/19918 , PT, OCS Marquette, MI Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. > > > <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> > > > 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 14, 2010 Report Share Posted February 14, 2010 Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@... This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager [mailto:PTManager ] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 15, 2010 Report Share Posted February 15, 2010 This conversation is now getting down to the nitty-gritty, which is, of course, all about pricing. Pricing is the magic language of commerce that occurs between consumers and producers/providers---it is the tangible picture of the intangible relationship between what consumers want and what producers/providers are selling. Political and forces have caused certain of our economic sectors to be insulated from meaningful pricing. Medical care is probably at the top of that list (e the mortgage market is another current hot spot). The true value of medical care has been clouded by mandates, incentives, tax rules, and government and private third-party participants. Each of those forces stand squarely between the patient and the provider, interfering, or completely controlling, that most delicate and important relationship. When we complain that we can't get paid for this or that, we are really complaining that someone other than the patient is acting as the customer. Government bureaucrats, or rule-makers, or corporate lackeys---each represents a false “customer†of sorts, and is determining value in the true customer's stead. It is extremely frustrating for providers to deal with value-determiners who have no personal interest in the transaction, but that is all providers will ever get as long as our payment systems clog the patient/provider communication arteries. The only way to fix the mess is to allow the patient to once again become the customer. That’s why we should support unencumbered health care savings accounts. HSAs will promote the real, honest, patient/provider communication that all good providers want. (And if our socio-political forces decide that government should fill the accounts, then so be it, but I doubt that any government intervention will sprout up without so many strings attached as to make it worse than useless for the individual.) Dave Milano, PT, Rehabilitation Director Laurel Health System ________________________________ From: PTManager [mailto:PTManager ] On Behalf Of thomas m howell Sent: Sunday, February 14, 2010 10:48 PM To: PTManager Subject: RE: Re: Insurance Reform Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@...<mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 15, 2010 Report Share Posted February 15, 2010 This conversation is now getting down to the nitty-gritty, which is, of course, all about pricing. Pricing is the magic language of commerce that occurs between consumers and producers/providers---it is the tangible picture of the intangible relationship between what consumers want and what producers/providers are selling. Political and forces have caused certain of our economic sectors to be insulated from meaningful pricing. Medical care is probably at the top of that list (e the mortgage market is another current hot spot). The true value of medical care has been clouded by mandates, incentives, tax rules, and government and private third-party participants. Each of those forces stand squarely between the patient and the provider, interfering, or completely controlling, that most delicate and important relationship. When we complain that we can't get paid for this or that, we are really complaining that someone other than the patient is acting as the customer. Government bureaucrats, or rule-makers, or corporate lackeys---each represents a false “customer†of sorts, and is determining value in the true customer's stead. It is extremely frustrating for providers to deal with value-determiners who have no personal interest in the transaction, but that is all providers will ever get as long as our payment systems clog the patient/provider communication arteries. The only way to fix the mess is to allow the patient to once again become the customer. That’s why we should support unencumbered health care savings accounts. HSAs will promote the real, honest, patient/provider communication that all good providers want. (And if our socio-political forces decide that government should fill the accounts, then so be it, but I doubt that any government intervention will sprout up without so many strings attached as to make it worse than useless for the individual.) Dave Milano, PT, Rehabilitation Director Laurel Health System ________________________________ From: PTManager [mailto:PTManager ] On Behalf Of thomas m howell Sent: Sunday, February 14, 2010 10:48 PM To: PTManager Subject: RE: Re: Insurance Reform Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@...<mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 15, 2010 Report Share Posted February 15, 2010 This conversation is now getting down to the nitty-gritty, which is, of course, all about pricing. Pricing is the magic language of commerce that occurs between consumers and producers/providers---it is the tangible picture of the intangible relationship between what consumers want and what producers/providers are selling. Political and forces have caused certain of our economic sectors to be insulated from meaningful pricing. Medical care is probably at the top of that list (e the mortgage market is another current hot spot). The true value of medical care has been clouded by mandates, incentives, tax rules, and government and private third-party participants. Each of those forces stand squarely between the patient and the provider, interfering, or completely controlling, that most delicate and important relationship. When we complain that we can't get paid for this or that, we are really complaining that someone other than the patient is acting as the customer. Government bureaucrats, or rule-makers, or corporate lackeys---each represents a false “customer†of sorts, and is determining value in the true customer's stead. It is extremely frustrating for providers to deal with value-determiners who have no personal interest in the transaction, but that is all providers will ever get as long as our payment systems clog the patient/provider communication arteries. The only way to fix the mess is to allow the patient to once again become the customer. That’s why we should support unencumbered health care savings accounts. HSAs will promote the real, honest, patient/provider communication that all good providers want. (And if our socio-political forces decide that government should fill the accounts, then so be it, but I doubt that any government intervention will sprout up without so many strings attached as to make it worse than useless for the individual.) Dave Milano, PT, Rehabilitation Director Laurel Health System ________________________________ From: PTManager [mailto:PTManager ] On Behalf Of thomas m howell Sent: Sunday, February 14, 2010 10:48 PM To: PTManager Subject: RE: Re: Insurance Reform Hi , Absolutely a great point to make and one I agree with. Health and consumerism in low income areas is an interesting thing to explore and understand. I too have worked in areas of all different socioeconomic status and have seen the differences. There still is some choice involved in most states even in those served by Medicaid and I would bet that they still will gravitate to clinics and providers they feel provide the best value, and even more important, those providers that understand what they go through to live and survive and any cultural issues that need to be addressed. No matter what side you tend to be on in health reform, it is unthinkable to downplay the need for us to take care of those that need care but cannot pay for it. Yes, some people milk the system and some need the system due to their own negligence of their health but there are still millions of people that need help through no fault of their own. More importantly, the value of care that they receive should never be inferior to any other but unfortunately, at least what I have seen, tends to be. Our clinic, whether seeing Medicaid clients (yes, even a private practice can survive and take Medicaid clients) or offering pro bono care which is part of our mission, we treat everyone the same and provide the same value to all. Tom Howell, P.T., M.P.T. Howell Physical Therapy Eagle, ID thowell@...<mailto:thowell%40fiberpipe.net> This email and any files transmitted with it may contain PRIVILEGED or CONFIDENTIAL information and may be read or used only by the intended recipient. If you are not the intended recipient of the email or any of its attachments, please be advised that you have received this email in error and that any use, dissemination, distribution, forwarding, printing or copying of this email or any attached files is strictly prohibited. If you have received this email in error, please immediately purge it and all attachments and notify the sender by reply email. _____ From: PTManager <mailto:PTManager%40yahoogroups.com> [mailto:PTManager <mailto:PTManager%40yahoogroups.com>] On Behalf Of Sent: Sunday, February 14, 2010 6:20 PM To: PTManager <mailto:PTManager%40yahoogroups.com> Subject: Re: Re: Insurance Reform Hi Tom, I think cost as a factor directly correlates to the socioeconomic status of the geographical area where one is practicing and the general trend of the economy. I've practiced in both a high income area and a low income area and they are distinctly different. In the high income area, I had a patient offer my twice my going rate in cash just to be seen at his convenience. I also had patients tell me I did not charge enough for my service. In the low income area, I've never experienced either of those situations. The discernment between higher and lower value PT services seemed to be sharper in the high income area as compared to the lower income area as well. Cash only practices can thrive in an area like NYC but I question how well they would do in rural North Dakota, for example. Also, as the economy trends downward again within the next year or two (as many indicators suggest it may), it will be interesting to see how well the cash only practices do. If one is serving the financial/political/business elite, one should be able to make a go of it but it think if one's case load is primarily middle class, they will see their business fall off. Time will tell. , PT, OCS Re: Insurance Reform Mr. Howell, Though I agree that we as a profession need to do a much better job of conveying a greater sense of value for our services, I stand by my assessment of a cost conscious consumer. My belief is based on current evidence/trends seen in many clinics. Most Medicare beneficiaries are upset at the cap. Many if not most Medicare patients are concerned that their therapy does not exceed the cap so they won't have to pay out of pocket. The patient with the high $1500.00 deductible tends to request fewer visits and places a greater emphasis on a written home exercise program. Even patients with a $30.00 copay (I've seen as much as $50.00+ per visit) seem to be questioning " the old standard order " for 3x/wk for 4 weeks. These factual examples are why I believe our patients are very cost consciousness. I understand the point that insurance has played a part in limiting the public's perception of value. In addition, I also agree that the public will pay out of pocket IF and only IF the perceived value is there. However, recent evidence seems to indicate that the public does not currently value physical therapy services enough to " pay extra " for them. In short, cost IS an issue. From a PT point of view, the idea of eliminating the difficulties related to a third party payment system and moving towards a personal pay system has merit. However, from a patient's point of view, exchanging their current status quo (insurance coverage) for a personal pay system would probably be a very hard sell. Jon Mark Pleasant, PT Methodist Medical Center > > > > > > > > > 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 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. <http://www.dol. <http://www.dol. <http://www.dol.gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> gov/ebsa/regs/fedreg/final/2000029766.htm> 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 > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 19, 2010 Report Share Posted February 19, 2010 Physical therapists can make a rehabilitative diagnosis that avoids labels (eg: hip bursitis) and focuses on activity limitations and body structure/function limitations. Consider the following: Patient can't... * climb stairs, * walk faster than 3.1 ft/sec. * Reach over 8 inches in standing * has depression and is taking Elavil * and uses a straight cane due to... * stiff hip abduction ROM * weak knee extension * impaired single leg standing * impaired tandem standing * elevated fear-avoidance beliefs * short heel cord * low balance confidence (note that this patient may be " diagnosed " as high risk for falls based on validated predictor variables) The first set of measures is easily recordable by any health professional (but frequently is not) while the second set of measures tends to fall into the domain of physical therapy tests and measures. Note that the rehabilitative " diagnosis " implies the treatment. Also, consider whether PT diagnosis has the same relevance today as when Rose, Guccione, Sahrmann and Jette wrote their articles - evidence based decision 'rules' now contain prognostic information that predicts outcome, # of visits and who needs what treatment. Why do PTs need a diagnostic label anymore? Finally, the " diagnosis " of function falls within the WHO ICF <http://www.who.int/classifications/icf/en/> disablement model that is complementary to the WHO ICD <http://www.who.int/classifications/icd/en/> (9 & 10) that physicians use to code their diagnoses for billing and health care policy making. Since everyone is functional but not everyone is affected by pathology or disease the ICD is eventually going to become subordinate to the ICF. This video by Dr. Jerold Stucki <http://www.fhs.usyd.edu.au/flash_video/stucki_presentation.shtml> helps explain this last point. Also, consider your sources, Dr. Jerome Groopman has come out strongly against evidence-based clinical decision rules (CDR) - for no other reason than he thinks they stifle the ability of physicians to make independent decisions. In his book, How Doctor's Think, he explores his perspective on physician decision-making without offering a better alternative to EBM or CDR. The web page link <http://www.jeromegroopman.com/articles/whats-the-trouble.html> in the prior post is an essay from his book. So, congratulations on having this discussion within your faculty - you've entered an exciting and transformative area of physical therapy that will guide our profession for many years to come. Tim , PTwww.PhysicalTherapyDiagnosis.comTimRichPT@... > > > Todd > > I finally carved out time yesterday evening and watched the youtube video you shared below. Like the PBS video that someone on this listserv recommended of the Cigna executive several months ago, I believe these are must see videos for all healthcare professionals. The youtube video is humerous and poignant at the same time. Thank you for taking time to share this and I hope others will take time to watch it as well. More importantly, if it hits a mark like it did with me, Ihope they will forward it to other healthcare professionals. > > Jim <///>< > > > > > 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 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 > > > > Quote Link to comment Share on other sites More sharing options...
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