Home Forums Discussions General Discussion This is simply not fair. Is it illegal?

I requested Anthem review my reimbursements on several in house procedures which I do because they are paying much less than the other insurance companies and even less than Medicare. Here was their reply:


> Dear Dr. Strouse,
>
> You can certainly submit a request for an increase in the current fee schedule. Once received, it will be reviewed and presented to the Reimbursement Committee for consideration. To assist with the analysis of your request for a fee review, a proposal should include the following:
>
>
>
> * Practice demographics (locations, number of practitioners and license held, years in practice, certifications/accreditations)
> * Please provide names/locations of facilities supported.
> * What percent of patient base is Anthem?
> * What counties do you draw patients from?
> * Since Anthem reimburses from a statewide fee schedule, please include justification as to why practice should be considered for an increase (i.e., what services provided by the practice are unique and not generally provided by other practices of the same type)."
> * In-office labs are reimbursed according to Anthem's Reference Lab Fee Schedule and will not be considered for an increase.
> * J-codes are reimbursed at ASP + 6% and will not be considered for an increase.
> * E&M codes are not negotiable.
>
>
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> Anthem will not accept proposals submitted as an across the board or as a percentage of Medicare. Please email the proposal, attaching an excel table with requested CPT codes, and proposed fees for consideration

And my reply:

Thank you for your reply but I have a number of questions before proceeding. How can Anthem discriminate and pay one provider one fee and another something else as I know very well you are doing. It is against the law for me to do that. How does whether or not I provide unique services matter? If I provide a service, it should be reimbursed at the same rate as others providing the same service which I know you are not doing. Otherwise, one might construe this as being collusion on Anthem's part as regards to knowing and discussing what other providers are charging and accepting. It is against the law for me to do that. I believe before I send you any additional information, I will consult an attorney on these issues. In the meantime, I will stop performing these services on Anthem patients and instead refer them to the more costly providers.

Yes, it's quite unfair.

Unfortunately,Leslie, it is also quite legal.

I hope they give you some better attitude after reading your letter, though I suspect they will not care at all.

We all probably know this, but it merits repeating. Doctors are not very organized in their efforts to be treated well by the insurance companies.

If physicians strike, patient care goes down. Most physicians can't see themselves putting the patients at risk, and the insurers take full advantage.

My $0.02

Insurance companies are exempt from anti-trust. One of the things health care reform talked about was repealing it, but that went silent real quickly.

In response, I would reference their letter.
Questions 1,2,4 they should know better than you. They know where your patients are from, they know your certifications. Again point this out to them.

State that Question 3 would be considered anti-trust on your part and should not be devulged. It should be made clear that your leaving the service area would have a detrimental impact to their ability to service their patients.

6,7,8 state J codes, E&M are off the table

# 5 Suggests that all providers in the state get the same money. Please ask to know the variance as it applies to your state. You should then get the maximum since you work in a Medically Underserved Service Area.

It is reasonable to pick the codes that you are most interested. Since the majority of codes fall in 6,7 and 8, this may be a small number.

It should be pointed out to them that since they are significantly below what others reimburse, you will exit their market and make it even more difficult for their patients to seek services in an underserved area.

I will tread lightly here with antitrust and all. But, I consider myself a thoughtful, caring and ethical physician, but I wouldn't consider patient care at all if I could strike. They would get their care at the emergency departments, until.....well I won't go on due to the whole antitrust issue.

Hi! (Yup, I'm still alive... )

It is a little known fact that health insurance companies are exempt from the antitrust laws. A law passed at the end of World War II, the McCarran-Ferguson Act of 1945, exempts health insurance companies from the federal anti-trust legislation that applies to most businesses. Actually, the law gives states the authority to regulate the business of insurance without interference from federal regulation, unless federal law specifically provides otherwise.

It's repeal comes up every once in a while in Congress, but they never seem to get rid of this exemption, even when lopsided numbers in both parties want it repealed.

"Under the exiting exemption, federal authorities can?t investigate or take action against insurers, even for blatant anti-competitive conduct like price-fixing or market allocation," notes Durbin, a member of Leahy?s judiciary panel.

URL: http://thedemocraticdaily.com/2010/...eal-health-insurers-antitrust-exemption/

So until they repeal this 65 year old law, it'll be an insurance abuse free-for-all and there is nothing that we can do about it! <sigh>

Cheers,
Al

Hi, the lunatic fringe here, again...

With all due fondness and respect, Leslie, I wish to quote from Ann Landers: "No one can take advantage of you without your permission." Is Anthem a managed care company, where you signed an agreement to provide care for what they feel like paying? Or, is it just an insurance company? If the latter, why do you care what they reimburse for a given code? Tell the patient "these are our charges", expect payment, and suggest they take it up with the state insurance commission if they feel the company is not living up to their end of the deal. If the former, then why not rethink that decision?

Individual charges from those of us in primary care are rarely so great as to make a huge impact in an average family budget. Of course there are exceptions, and truly impoverished areas, but I don't really feel too terrible about asking $150 - $300 from a family who just bought two new snow machines.

Thanks for all the terrific replies...I agree with them all. Al!!!!! It was terrific to hear from you! You have been missed.
Wendell, I really like your suggestions and I will respond to Anthem this way. Ansharda, I have thought long and hard about what a physician strike would do. Although I am basically in favor, I cannot commit financial suicide. I am fairly certain there would be too many "scabs" for it to work. And, I would see it as a great opportunity for insurance companies to push the door wide open for mid-levels to take our places. David, yes I am contracted with Anthem but those contracts were signed years ago when Anthem happened to be the better payor in the local market. I am not an Anthem Medicare provider because I refuse to sign a whole new Anthem contract, which I would have to do.
No, I really do not see anything happening until and unless we remove the decision for one's health care from the control of the employer. As long as corporations are choosing the plans for people, there can be no free market pressures. Employers care only about meeting federal mandates. And, the more cheaply they can do this, the better for them (which I have no problem with in theory). If each employee were given the money their employer spends on them for health insurance and researched and bought their own policies I believe we would see more equity for all. There would be no physician/insurance contracts. Insurance companies and providers would all have to be more competitive within their own markets.

Well stated Al!

It's crazy that we cannot even get together and decide in one town to drop Insurance X. However, Blue Cross can rule the whole town, tell all the docs they have to take BC, and withdraw all their patients if you do not give into their terms. How did we get into this position, and how do we get out?!

Shakespeare said it best:

"The first thing we do, let's kill all the lawyers". - (Henry VI, Part 2, Act IV, Scene II).

As soon as we aren't afraid to form a union.

Doctors are too busy to fight these issues and we are innately not programed to turn against our patients. That is where a strong medical association should come in. Unfortunately, the AMA has, IMO, done very little to advance our profession. It might be easier to withdraw from these non-representative societies than trying to unionize doctors. Left unfunded, the AMA would surely HAVE to start listening to physicians.

I don't belong to the AAP, AMA, MMA or MMS. When I used to belong to the MMA, at least I got A LOT of free legal advice that was helpful.

I alway love that the Maine Medical Society wants me to pay dues and then I hear from them once a year about the annual picnic.

Personally, I find most of the organizations to be rather useless. I am actually in the middle of a four shot series of rabies shots for an 8 yo, when I got an email from the AAP announcing new guidelines for post-exposure animal bites. I tried to read the article, but I couldn't because I am not an AAP member. Now, you will tell me I should be and not to complain, but I find it pathetic that an organization devoted to the health and well-being of children will withold information because I am not a member.

OK, charge me for the Red Book and charge me for your conference but don't email me with vital info and then withold it from me.

@Leslie You are completely right, but it is sad, that for the same reason doctors won't fight the system, they are't going to not pay these huge organizations.

I personally think we should unionize and, if the government wants to call that antitrust, then go to court. Unfortunately, they have that little thing they call the licensing board that can simply pull your license.

I find the problem is there just isn't enough public opinion or knowledge of the plight of primary care physicians.

While the number of people who are avid sports fans is relatively small compared with the overall population, virtually all of the sports fans know of the lockout. And, support for the owners and players is around 50 - 50. This, even though the average salary is almost $1,000,000. (Average career is 3 to 4 years).

When Hurricane Katrina hit, my guess is that nearly the entire population over 12 years old knew about it within 24 hours. I am guessing that over years maybe 5% of the public know what PCPs are reimbursed for Medicaid and Medicare. I would bet that most people would have little sympathy for physicians and have no idea the number of hours worked and the average salary minus the loans.

As a quick example, my automobile insurance company was sued after an automobile accident I was involved in. The amount of coverage I had left me short of the amount asked for. The attorney for me (hired by the insurance company) kept advising me to pay the difference of $50,000, because if it went to court, a jury could award much more. He just didn't seem to understand that although I was a rich physician, I just didn't have $50,000 lying around in a bank account.

Leslie, keep in mind that the AMA holds the rights to the CPT codes and collects royalties from anyone who uses them. The Wall Street Journal estimated their income from this at $70 million annually. Many people think the organization also dramatically overstates the percentage of physicians it represents.

So I agree that we should not be members, but even so, they will still have plenty of money and will continue to claim to represent us (even if they don't).

Jon,

I see your point.

Bert,

Many years ago, (about 1994?) doctors in NJ went on strike for about 4 hours (something like that, can't remember the details).

Boy, did it get the attention of the state's legislature.

I really don't even remember the issue that they walked out for, but based on the response, if physicians ever formed a union, it would carry power, lots of power.

I agree. Tons of power. It's crazy that we aren't. And, I know it would be risky. But, most things that have changed history required sacrifices.

I still think it also comes down to educating the patients. They won't be too sympathetic to some sort of strike if they think we all make $500,000 a year and have three sports cars. Every once in awhile the topic comes up with a Mainecare patient. They are shocked when they hear what we are reimbursed compared to private insurance.

We had a patient once (We stopped taking Medicare, so he had to get another Dr.). One of our favorites. Well, one day he came in and told Alice and I that we must have made a mistake on the billing, because they had to pay her more than THAT! "I don't want my doctor to be poor and angry and resentful, I want my doctor to be rich and happy to help me!" Yep, that's what he said.

We do miss him.

Bert is right: The public needs to be educated.
If you total the profit that the "Healthcare Companies" in the United States made in 2010 it would pay for the actual medical care needs of every citizen in the country. I feel if all physicians would refuse to accept payment from ANY source except the patients and the government the "Healthcare Crisis" would not exist.
Providers would be able to:practice medicine for the patients benefit and not for the insurance companies profit; schedule test and labs and write prescriptions that the patients actually need; operate with two FTE instead of four or five; spend 15 to 20 minutes with patients instead of 5 or 10;etc. etc.

For political answers check out GOOOH.COM

When we opted out of Medicare, we did have these discussions with our patients. Universally, they were understanding and sympathetic.

BUT....

The fact is, a lot of medical care is hugely expensive. And you and I know that when push comes to shove, we are going to take care of people. So does Blue Cross, and so does CMS.

In opting out of Medicare, we are now free to use private contracts without fear of being charged with fraud if we reduce charges. It is really quite freeing. Now, if I get paid $15 for an office visit, I at least know I did so voluntarily and feel good about it. It's having some officious jerk in an office in Seattle tell me I'm not worth any more that made me crazy.

Crazy, but where I am, Medicare is almost always my top payor and definitely the easiest to work with. Negative side, it is government and intrusive and getting more and more demanding of stupid crap like MU.

naive question but
are there or have there been insurance companies owned by physicians? I am aware that many of the insurance companies have MDs in executive positions but none seem physician friendly - there are physician owned groups that sell malpractice insurance, physician owned hospitals, etc.

Perhaps the two functions are inherently at odds. I have a contract from Coventry on my desk .. been shifting it from one side of my desk to other for a week - used to do the same with blackeyed peas on my dinner plate ... was just thinking how nice it would be to enthusiastically sign an aggreement ... to partner with an insurance company with an ethos similar to AC's.

AC and other EMRs were born out of frustration with charting - docs have been frustrated with insurance for decades - why no equivalent product evolution?

Supposedly, Atlantis.

Gino, I asked the question a while back, and one of the board members, I think NeproDoc (need to lookup the handle), went through this whole process with a group of Docs, and the big show-stopper for them was to become an insurance company, they needed ~2Million US in reserves to get started, which in their case meant partnering with an insurance company. The process went downhill from there as the motivations of the InsCo and the Doctors was diametrically apposed. That is my free-hand retelling; if I can find his actual post I'll come back later and edit to add it.

From my perspective of having done many startups and dealing with Angels, VCs, private Investors, etc. I have seen many millions more thrown at far risker ventures, and far iffier founders than a bunch of licensed, practicing Doctors.

That said, I'd throw in with a bunch of Doctors to form a Doctor-controlled Insurance company; I'd say that path is easier/faster/less-problematic than unionizing, and raising the capital always takes work, but given the possibilities, I'd say it would easier than most that I have been involved with.

I would *LOVE* to see KP,BC/BS,Aetna, etc have an effective competitor. It would be just the kind of fight I like to pick; but then that is why I like startups instead of being part of the enterprise borg.

For a number of years, I was on the board of our state owned and doctor managed malpractice insurance company. There is a huge amount of stuff that went in to it, even for a really small client base. The doctor expertise and input starts to get diluted out very quickly amidst all the other disciplines that need to be represented; investments, claims, legal, actuarial, marketing, accounting, underwriting, etc. The doctors would be able to budget a couple of days every quarter for the board meetings, but the real day to day action took place by the same sorts of folks who worked for any other insurance agency. I think you would be disappointed in just how different it could actually be in the long run.

David,

Thanks for sharing your experiences; I understand that there are a variety of functional groups, and perhaps I am just too much of the wild-eyed dreamer.

On the other hand, I have seen seen the same type company run completely differently, so I wonder how much is architecture via social engineering since most folks come from other insurance companies, and so that is what they build and expect.

So I won't by any means minimize the challenges, but I think that, at the very least as a thought-experiment, it is a worthwhile endeavor.

Who knows better how to make an un-insurance company than the folks who have to deal with them all the time?