TMA vs. Cigna

Cigna Referral Policy Draws TMA Challenge

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Tex Med. 2013;109(11):43-45.

By Amy Lynn Sorrel
Associate Editor

Texas Department of Insurance (TDI) regulations on preferred provider networks were barely a month old in August when the Texas Medical Association renewed its challenge of a Cigna practice the association says violates state law and could prevent physicians from giving their patients the care they need.  

TMA filed the complaint after Cigna notified physicians it will continue enforcing an old policy on out-of-network referrals. Barring an emergency, every time Cigna patients plan to leave the network for just about any type of care, their physician must fill out a form explaining and acknowledging the referral, whether or not the patient follows through on it. Physicians also must disclose in writing any kind of financial interest in the physician practice or facility to which they are referring a patient, or check a box even if they don't have an interest. The referral could include another physician, lab, facility, surgery center, or other out-of-network entity. Doctors must keep the document indefinitely, and they are subject to audits by Cigna.

Physicians who violate the policy risk losing their preferred provider network status, their contract, or payment. TMA's Payment Advocacy Department is tracking related complaints from physicians. In at least one instance, TMA was told a physician had to appeal Cigna's payment denial when he referred to an out-of-network pathologist, even though the health plan at the time had none in the network area. The appeal has not been resolved yet.

Cigna says the policy curtails inappropriate out-of-network referral practices and protects patients and employers from excessive costs. 

But the form appears to "put an obstacle between patients and their basic insurance coverage and right to access care," said TMA Vice President of Medical Economics Lee Spangler. "There are other tools Cigna can use to address abuses [of out-of-network referrals]. Cigna has chosen instead to impose a policy that burdens all physicians."

TMA is asking TDI to review the legality of the Cigna policy and its impact on patients and to consider "all possible sanctions" against the insurer. They range from barring use of the form to fines.

State law does not put TDI under any kind of timeline to respond to complaints. A spokesperson says the agency contacted Cigna within weeks of receiving TMA's complaint and was reviewing the health plan's response in light of the new regulations. 

At It Again

TMA filed a similar complaint with TDI about the policy when Cigna first imposed it in 2010. TDI didn't take any action back then, possibly because the new rules were still being developed. At press time, TDI was still reviewing the latest complaint.

In the first complaint, TMA officials alleged the Out-of-Network Disclosure Form violates state laws guaranteeing not only patients' right to freely choose any physician or other provider without restriction by an insurer, but also physicians' right to discuss and recommend all treatment options to their patients. TMA reiterated the same stance three years later. 

In addition, TMA officials say, Cigna's policy is more troubling now because it appears the company has not sufficiently adapted the policy to fall within the limited scope of the new TDI regulations that address network adequacy and general market conduct. (See "Adequate to Inadequate," March 2013 Texas Medicine, pages 21-25)

Despite TMA's objections, TDI approved regulations allowing health plans to require physician disclosures when they have an "ownership interest" in an out-of-network referral "facility." Having to disclose a broader "financial interest" in entities other than a facility, however, goes beyond what TDI allows, Mr. Spangler says. The form forces physicians to disclose a financial interest even if it's not relevant, for fear of leaving something out and being penalized. 

TMA Payment Advocacy Director Genevieve Davis adds the policy puts physicians in the position of having to educate patients about Cigna's policies, when their primary focus should be giving them the care they need. If patients believe their doctor is acting on behalf of the insurance company to deny care, rather than in their best interests, that could interfere with the patient-physician relationship. 

Cigna's Defense

Cigna declined Texas Medicine's request for an interview. In a written response, Cigna executives Mark Netoskie, MD, and Frederick Watson, DO, said the out-of-network form helps patients make informed decisions. 

"Cigna contracts with health care professionals so that our customers can obtain the primary and specialty care they need at an affordable cost. In most situations, our customers expect to receive medical care from doctors and facilities that are in Cigna's network, even if their doctor refers them elsewhere," they wrote. "We also believe that individuals have a right to know if their doctor has a financial interest in the practice or facility to which they're being referred."

They said some out-of-network health care professionals or facilities charge fees up to 1,000 percent higher than market rates or forgive patients' responsibility for their share of out-of-network charges. The Cigna representatives acknowledged that most out-of-network professionals do not do such things, but said those who do hurt local employers and consumers when those costs are passed on in the form of higher premiums or reduced health care coverage.

The form, on the other hand, helps protect patients from what Drs. Netoskie and Watson described as "unwelcome surprises" from out-of-network billing.  

"If Cigna customers have out-of-network benefits, they're free to choose out-of-network services in partnership with their physicians. However, we believe they have the right to understand the consequences of that choice and have all the facts. We also think it's important for Cigna's in-network doctors to be part of the conversation through the use of the out-of-network form."

Cigna says it shared the form with the state and is working with regulators to implement what Drs. Netoskie and Watson called an "important consumer protection." 

TMA does not condone inappropriate use of out-of-network referrals. TMA and AMA ethics policy encourage physicians to disclose any ownership interests when they refer patients to entities outside of their practices. At the same time, TMA policy opposes health insurance company policies or procedures that discourage or interfere with medically necessary referrals for out-of-network care by imposing requirements for physicians to obtain patient signatures, sign documents disclosing ownership interests, make telephone calls, or obtain notification numbers. 

Amy Lynn Sorrel can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email.

SIDEBAR

Insurance Hassles? TMA Can Help

TMA wants to know about your insurance hassles. Contact the Payment Advocacy Department's Hassle Factor Log to report issues so TMA can investigate and work with health plans to help get your claims paid correctly. 

Download the Hassle Factor Log and learn more about the program or email the TMA Payment Advocacy staff for assistance. You also can contact the TMA Knowledge Center at (800) 880-7955.   


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