New CIGNA Policy Adds Administrative Burdens for Physicians
Medical Economics Feature – April 2011
Tex Med. 2011;107(4):51-53.
By Ken Ortolon
Patients who pay for out-of-network benefits should have the right to use those benefits, the Texas Medical Association believes. But TMA fears that a new policy CIGNA implemented in December is designed to discourage enrollees from using their out-of-network benefits and will create huge administrative hassles for physicians who refer patients to out-of-network providers.
TMA officials say the policy requires physicians to document that they told patients that they are being referred to out-of-network providers and to keep the documentation in their records indefinitely.
Plano family physician Christopher Crow, MD, chair of TMA's Council on Socioeconomics, called the policy "completely burdensome" for physicians. He says it probably violates laws that ban health plans from imposing gag clauses to prevent doctors from discussing all treatment options with patients.
Just three days after CIGNA announced its new policy, TMA filed a complaint with the Texas Department of Insurance (TDI), contending the CIGNA policy interferes with patients' rights to use their insurance benefits.
But just days later, TDI proposed new network adequacy rules that likely would permit the type of policy CIGNA has implemented.
Where's the Benefit?
On Dec. 13, CIGNA informed its participating physicians that they must complete a form attesting that they have told patients they are referring them to an out-of-network physician, hospital, ambulatory surgical center, or other provider.
The form requires the physician to say whether an in-network alternative was offered, disclose any ownership interest in the out-of-network facility, and list the reasons why the out-of-network referral was necessary. The physician must sign the form and have the patient sign a section attesting that he or she has chosen to seek care out of network.
Finally, the physician must keep the form on file indefinitely.
In a letter to physicians, CIGNA said that use of the form "is a condition of participation" for physicians and other health care professionals in their health plans and that the company may audit use of the form.
Also, the disclosure form urges patients to contact the CIGNA HealthCare Special Investigations Hotline if any out-of-network provider offers to waive or forgive any part of their charges.
In its letter, CIGNA contends that most patients with CIGNA coverage who seek care from an in-network physician expect the treatment will be reimbursed using in-network benefits.
"Patients with CIGNA coverage who have out-of-network benefits are free to choose to use these benefits for covered medical services," the letter stated. "In doing so, they will generally incur higher out-of-pocket costs.
"To help ensure that patients are making informed choices regarding whether to seek care from participating or nonparticipating health care professionals or facilities, they must have full disclosure regarding the financial impact of such referrals under their benefit plans, including the referring physician's financial interests, if any," the letter continued.
While the letter acknowledges patients' right to use out-of-network benefits, Dr. Crow says it is obvious CIGNA is attempting to discourage them from using those benefits, "which I understand from a cost standpoint. But they signed up to have those benefits."
Gagging the Doctor
In a Dec. 16 letter to Doug Danzeiser, TDI deputy commissioner for regulatory matters, Dr. Crow contended that CIGNA may be violating Texas Insurance Code provisions that insurers cannot, as a condition of a contract with physicians, prohibit or discourage them from discussing all treatment options with patients.
"TMA asserts that the CIGNA disclosure form policy is intended, directly, to discourage a physician from discussing and/or recommending treatment options and services that are out of network," Dr. Crow wrote.
Even if physicians wanted to comply with the policy, Dr. Crow says it's almost impossible to know the network status of every physician, hospital, or other provider to whom they might refer a patient.
"It is not in our ability, especially in a community like Dallas, to know every single doctor and what their relationship to CIGNA is," he said.
The complaint letter also asks what happens if a physician refers a patient to an in-network hospital or ambulatory surgical center for surgery, then discovers the anesthesiologist or pathologist at that facility is out of network.
"Will this be a circumstance that a physician must consider under this new policy?" Dr. Crow asked. "If so, this would be a tremendous administrative burden."
He also asked whether physicians would be responsible if they refer the patient to an in-network physician or provider, but by the time the patient actually received the services the physician or provider is no longer in network.
"One can't rely on the provider directory on the website, since that is not updated on a regular basis, and physicians are not privy to other physicians' contracting status with CIGNA," Dr. Crow wrote to TDI.
"We shouldn't be responsible for knowing an entire medical community's status on a particular insurance plan," Dr. Crow said in an interview with Texas Medicine. "That's just crazy."
If CIGNA wants to save money by forcing enrollees to receive care in network, the company should do it with its benefit design, not by forcing physicians to do it for CIGNA, he adds.
TMA also complained about the language in the form directing patients to report offers to waive or forgive some charges to CIGNA's investigations hotline. That directive disregards the fact "that debt forgiveness can be entirely appropriate," Dr. Crow wrote. "TMA is concerned that such a warning will mislead and deceive patients into the incorrect conclusion that debt forgiveness and waiver is always a fraudulent activity."
TMA's Payment Advocacy Department asked CIGNA for answers to the questions Dr. Crow raised, but it had not responded as of mid-February.
Rulemaking End Around
It is unclear when TDI may act on TMA's complaint. In mid-February, a TDI spokesperson would say only that the agency is "looking into it."
But TMA officials don't expect a TDI decision until it has finalized the rules on network adequacy it proposed shortly after TMA filed its complaint. Those rules include a new section that specifically allows insurers to require referring physicians or providers to disclose to patients that they are being referred out of network. Additionally, referring physicians must disclose if they have a financial interest in the out-of-network entity.
In testimony on the proposed rules, former TMA President William Hinchey, MD, of San Antonio, said TMA foresees that the requirement could impact delivery of care to patients due to "incredibly burdensome" administrative policies.
"These burdens will delay necessary medical care from the physician identified by the referring physician as the best to provide the necessary care," Dr. Hinchey said.
A 30-day comment period on the proposed rules ended in late February, and a TDI spokesperson said the agency has up to six months to finalize the rules. If approved, those rules would take effect Jan. 1, 2012.
Ken Ortolon can be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by e-mail.
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