Cover Story - June 2006
By Ken Ortolon
When Austin urologist Stephen Hardeman, MD, removed a kidney from a living donor so it could be transplanted in the man's wife, Blue Cross and Blue Shield of Texas Inc. declined to pay for the procedure under the wife's coverage. Blue Cross initially paid Dr. Hardeman only $6 and charged the remainder of his fee to the donor's deductible because he and his wife were covered by separate policies.
"I thought that was outrageous," said Carol Slaughter, insurance appeals specialist at The Urology Team P.A., Dr. Hardeman's group. "I had never seen them apply a new, separate deductible when the donor was not a participant on the policy."
Blue Cross denied her appeal, so Ms. Slaughter used the Texas Medical Association's Hassle Factor Log ® to file a complaint in January. TMA in turn took the matter to a March meeting of Blue Cross executives, physicians from TMA's Council on Socioeconomics, and TMA Health Care Financing Department staff. The matter was quickly resolved. Dr. Hardeman was paid just over $2,000, and the organ donor was charged nothing.
"It was a pleasant surprise, and I was excited for the donor to not have to pay a deductible after donating his kidney," Ms. Slaughter said.
Dr. Hardeman's case is just one of thousands TMA's Hassle Factor Log program receives every year and one of dozens resolved through ongoing meetings TMA conducts with all of the major health insurance plans in Texas. (See "Hassle Log First Step in Resolving Health Plan Disputes.")
Wichita Falls pathologist Susan M. Strate, MD, chair of the TMA Council on Socioeconomics, says the hassle log and carrier meetings are valuable member benefits that not only help individual physicians whose claims are resolved, but also benefit all Texas physicians and the insurers themselves.
"The hassle log keeps TMA informed of what issues are out there. It helps us pick good issues to take to the carrier meetings. It helps us resolve some of these issues. It helps us understand what advocacy we need to do on the carrier front, on the legislative front, on the regulatory front."
TMA officials say passage of current state prompt pay statutes and their supporting regulations was a direct result of the overwhelming number of complaints about payment problems received through the Hassle Factor Log.
The log and the carrier meetings are just two of the many ways TMA is working to meet the TMA 2010 goal to protect, improve, and strengthen the viability of medical practices in Texas, Dr. Strate says.
"Whenever we can cut down on administrative hassle in the claims-filing process, that should cut down administrative hassles both for the physician and for the health plan."
Opening the Dialogue
TMA began the carrier meetings in 1990 when managed care was first gaining a foothold in the Texas market. "There were emerging issues in terms of coding, payment, and reimbursement," said Louis J. Goodman, PhD, the association's executive vice president and chief executive officer.
Dr. Goodman, who was then director of TMA's Division of Medical Economics, says the number of complaints received by the hassle log quickly mushroomed. So TMA requested the carriers participate in dispute resolution meetings.
"We asked them if they wanted to meet, or do we take them to court," Dr. Goodman recalled.
The initial meetings were held with the Medicare carrier, which at that time was Blue Cross. TMA now meets in the spring and fall with nine different carriers who make up about 80 percent of the Texas health insurance market. Participating insurers include TrailBlazer Health Enterprises (the state's current Medicare carrier), Texas Medicaid & Healthcare Partnership, Blue Cross, Humana Inc., Aetna, CIGNA, UnitedHealthcare, Unicare, and PacifiCare.
Dr. Strate says the health plans generally are very cooperative, although both Humana and CIGNA temporarily refused to meet with TMA while the association's federal antiracketeering lawsuit against them was proceeding through the courts. Both have since settled their portions of the lawsuit.
"The carrier meetings involve issues that impact physicians and carriers" Dr. Strate said. "Both physicians and carriers have to be involved collaboratively in the business of medicine, and we approach the issues in that way. If we sit down and talk about the issues, then frequently we will come up with ways in which we can cut down on administrative hassles."
TMA takes to the meetings both specific claims issues from individual physicians and more global issues dealing with carriers' policies on claim processing, code editing, and other issues.
Hassle Factor Log complaints are analyzed by TMA staff to determine what action is required. Many complaints are received as information-only items, such as when a physician sends a copy of a complaint that he or she has filed with the Texas Department of Insurance (TDI). Other complaints may request TMA assistance in resolving a dispute.
For those complaints, the TMA staff generates a letter to the carrier asking for the claim to be reviewed and the dispute resolved. The staff can choose from more than 30 form letters to request carrier action on items that are frequent problems.
"Believe it or not, the same issues occur over and over again," said Teresa Devine, director of TMA's Health Care Financing Department. They include complaints about downcoding, code editing, lost claims, lost medical records, requests for medical records, slow payment, preauthorization, and recoupments.
Claims that can't be resolved through correspondence or those that involve recurring issues are put on the agenda for the next carrier meeting.
Dr. Strate says TMA often resolves a dispute in a physician's favor. "Many times there are actually recovered dollars," she said.
Ms. Devine says it is hard to put a number to the actual success rate because TMA is not always informed of the final outcomes of the cases by the carriers or physicians involved.
TMA took five physician complaints to the meeting with Blue Cross. Four, including Dr. Hardeman's case, resulted in additional payments to the doctors.
In one case, for example, a Houston physician who had been trying since September to get payment of $4,410.39 filed a Hassle Factor Log complaint in January after calling Blue Cross repeatedly. He was finally paid in March.
Another complaint led to redrafting the letter Blue Cross uses to request medical records because a complaining physician felt it was inflammatory or accusatory.
"We took his example of the letter and we put it through the letter review committee," said Pat Lyell, RN, manager of the Office of Physician Advocacy at Blue Cross. "They agreed and it has been changed."
Dr. Strate says policy and systems issues are more difficult to resolve, but at times TMA can get the health plans to reconsider company policies or change their claims-processing systems to reduce hassles. Other times, when an issue cannot be resolved, TMA and the insurer simply agree to disagree, and TMA can use what it learned at the meeting to help educate physicians and their staff on how to deal with a company's policies.
Business as Usual?
Dr. Strate and other physicians who have participated in the carrier meetings over the years believe they are valuable, but they admit not all of the carriers bring the same level of enthusiasm to the meetings.
Dr. Strate says recently Medicare, Medicaid, and Blue Cross have cooperated and worked to correct problems. However, meetings with those carriers in the past sometimes were contentious. New management in the Medicaid program contributed to improved relationships, but TMA officials say the level of trust built up between the association and those carriers also has contributed to better cooperation. Blue Cross, for example, created its Office of Physician Advocacy to ensure TMA's issues are given the proper attention, Ms. Devine says.
Frisco gynecologist David Rogers, MD, has attended numerous carrier meetings as a socioeconomics council member and has mixed feelings about their value.
"There is a reason why we see the same issues over and over again. They [the carriers] are good at taking care of individual problems, but they often fail to correct the systemic issues that we find. They are always very cordial, but I think it's business as usual once we walk out of the room."
Paul Handel, MD, Blue Cross vice president and chief medical officer, has sat on both sides of the table at carrier meetings since he once chaired the Council on Socioeconomics. He says he still has a "burr under my saddle" from his days on the council over carriers who would not work in good faith with TMA to resolve issues. Council members and TMA staff frequently would "get the same platitudes when we walked in the door and never accomplish anything," he said.
"I don't know how I will ever convey to people the intensity of my feeling that the carriers that do not listen, carriers that basically do the stonewalling and the sandbagging remain an anathema to me," Dr. Handel added. "I believe all carriers ought to be extending themselves to organizations such as the TMA in an attempt to improve the relationships and the understanding as to what situations, what conditions, are truly driving the changes in health care today."
While there may be disagreement over what the carrier meetings accomplish, TMA leaders and health plan executives say they are important to improving relations among the health plans, their physician networks, and organized medicine.
Dee Whittlesey, MD, vice president in charge of the Blue Cross Office of Physician Advocacy, says her company sees the meetings as very positive.
"The issues that are brought to us are issues that are important for us to recognize and identify those things when we have stubbed our toe," she said. "Of course, we hope we don't do that too often, but we know we do. And then we look for the root cause as to how we can correct whatever issues there might be."
If Blue Cross doesn't feel it made an error, the meetings are an opportunity "to explain why something happened, what the rationale is," Dr. Whittlesey said. If the TMA staff members understand the reasons certain decisions are made, they can explain those reasons to physicians, she says.
Tyler Mason, vice president for public relations at UnitedHealthcare, says having an open dialogue facilitated by TMA is good for all Texans.
"We value the carrier meeting process and think it provides an opportunity for health plans to hear directly from physicians and to address issues that affect us all," Mr. Mason said.
As a result of a meeting with United executives in April, TMA resolved an issue for a Houston pain management group in which United was withholding income taxes out of claims payments because the group's form W-9 had expired. United continued to withhold taxes from claims payments even after the practice filed an updated W-9. TMA intervened and United refunded the pain management group more than $4,700.
Dr. Handel says the meetings really help put health plan executives into doctors' shoes.
"First and foremost, it gives the carriers a clearer sense of the issues that affect the physicians and their practices on a day-to-day basis. In doing that, it helps to keep the reality of what is going on in the offices in the forefront of the interaction between the carriers and the physicians."
Dr. Handel points to the Blue Cross Clear Claim Connection, which will enable physicians to look at the company's bundling logic when they submit a claim, as one example of what can be accomplished when the physicians and carriers discuss issues in good faith. The Clear Claim Connection was expected to be implemented in May or June.
"That is a direct result of carrier meetings and the concern that physicians had as to the lack of clarity surrounding bundling decisions and the edits involved," he said.
Ken Ortoloncan be reached by telephone at (800) 880-1300, ext. 1392, or (512) 370-1392; by fax at (512) 370-1629; or by email at Ken Ortolon.
Hassle Log First Step in Resolving Health Plan Disputes
Physicians looking for help in resolving payment, coding, or other claims disputes with health plans should turn to the Texas Medical Association's Hassle Factor Log program.
The Hassle Factor Log was created more than 15 years ago to help TMA gauge the types of problems physicians were experiencing with the administrative burdens of managed care. Through the log, physicians can submit claim problems to TMA and get assistance in resolving disputes with health plans.
To access the Hassle Factor Log, physicians can sign on to the members-only section of the TMA Web site at www.texmed.org and look for Hassle Factor Log Resources under Practice Management. Physicians can print the hassle log form or download it as a PDF. Forms also can be requested by telephone by calling (800) 880-1300, ext. 1414, or (512) 370-1414.
Completed forms should be mailed to the attention of the Health Care Financing Department, 401 W. 15th St., Austin, TX 78701 or faxed to (512) 370-1632.
Because of privacy concerns related to the Health Insurance Portability and Accountability Act (HIPAA), physicians also must complete a business associate agreement. The agreement allows TMA to view protected health information necessary for the association to help the physician with the resolution of his or her claim.
TMA Council on Socioeconomics Chair Susan Strate, MD, says HIPAA concerns have caused the number of complaints to drop in recent years, from a high of around 6,000 before 2002 to about 2,000 annually today.
Dr. Strate believes the Hassle Factor Log is underutilized, and she encourages physicians to submit their claim disputes to the log.
"This is really tremendously effective in terms of being a way for offices to get help with these issues when they're having trouble getting their claims processed correctly," she said. "Plus, it allows us to go back to the carrier, discuss it, determine what we need to do to educate physicians' offices to make the system easier to use, and to cut down the hassles for both the carrier and the physician."
TMA also offers its Mini-Consultation program to help physicians with coding, billing, reimbursement, denial of services, or claims-filing problems.
TMA staff travel to county medical societies across the state and conduct free 30-minute sessions with individual practices regarding these issues. Each physician or office staff member who attends receives a free mini-consult handbook full of helpful articles and reference materials, and a packet of information on TMA resources on managed care, practice management, and more.
Physicians can contact their local county medical society to schedule a mini-consultation.
Both the mini-consultations and Hassle Factor Log programs are free to TMA members.
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