"One Cannot Measure What One Does Not Manage": If You Lie Down with Dogs, You Get Up with Fleas (Part XIII-h)

May 7, 2009

A continuation of last week's post, "Lobbying with a Conflict of Interest."

(Continuation of last week's post, "Lobbying with a Conflict of Interest")

From: Fredrick H (MD, PhD, JD) Sent: Tuesday, April 07, 2009 8:15 PM


Jeff: A syllogism:

Major Premise: He who pays the piper calls the tune.

Minor Premise: UHC, an especially bad HMO, pays the Lewin Group.

Conclusion: United, for its own advantage, tells the Lewin Group what tune to play.

That said, who is surprised? Of COURSE a government-run health plan will give more value for the dollar, and be more attuned to patient needs than a greedy private HMO! And that is PRECISELY why we should be in favor of it.

From: Gilbert R (Academic PPO's Exec. Dir.) Sent: April 7, 2009 8:32:34 PM EDT

New York's Attorney General, Andrew Cuomo's attack on Ingenix was a brilliant political move, and one that he has milked to fund a NYS based, not for profit entity—the claims and coding database expected to be located at a NYS university.

However, in typical fashion, this issue, arising as it were from medical community complaints will result in less money AND less out-of-network services.

The community docs thought that by obtaining corrections to flawed calculations of out-of network benefits, there would be more money for OON, non-participating physicians. This would increase the number of patients that would take the option to use out of network; all they'd have to do was write off the patient portion, the difference between the “now” higher out-of-network reimbursement, and the physicians usual fee. (It was not an uncommon benefit to provide out-of-network at 80% of Usual and customary, and with such lucrative payments, physicians would waive the 20% that was the patient’s responsibility). But, waiving the patient portion is viewed as an illegal inducement to use that provider and may create a false claim. Indeed, there are, now, a growing number of physicians and ambulatory surgery centers that are being investigated. I have consulted to the legal counsel of one with a $1.3 million claim against it for writing off the patient portion.

While it appears that the Ingenix database was flawed, what has happened in bringing this issue to the regulators will result in the following:

* Higher costs of out of network resulting in higher premiums, resulting in employers cutting the benefit in whole or part. Employers are already being told that they can reduce their next year's premium increase by staying within the network. And in this economy, the employer says sure, and 'employee, be thankful you are working and have any insurance.'

* Movement of payers to cover at a percentage of Medicare: 100% of Medicare, or less. [Why would your out of network doc be so piggy as to demand more than Medicare, anyway?]

* The identification that a large number of out of network providers have been filing false claims — Shoot your self in the foot? The plaintiff physicians went to the AG to complain about OON referrals being reduced and now he wants the Plans to turn them in for writing off the patient portion. (A false claim is created when the patient portion is forgiven, but the claim is filed for the full amount. I.E.: claim $100, coverage 80% - $80, but with the write-off of the $20, the insurance company's responsibility is only 80% of $80 or $64.)

* Then there is the enforcement of par physicians' contract provisions to dissuade them from sliding their patients to non-par associates and facilities. All the plans are moving to increase the penalties for such nefarious acts, including termination and holding par physicians liable for the full cost of the out-of-network referral.

The net result will be a decrease in patients using out-of-network providers, and more out-of-pocket costs for those that do.

It is never wise to seek out the regulators to "help" you, they are not your friend, and will do what is good for them. Ink matters more to them than reality.

Yes, there are some issues with the Ingenix database, but the cure is going to be worse than the illness.

From: Fredrick H (MD, PhD, JD) Sent: April 8, 2009 11:09:52 PM EDT

Gil: This is the typical sort of reasoning that conservatives use to try to retain the status quo:

• Never try to fix an immediate obvious problem, because there might be some speculative adverse effect, far in the future.

• "Don't let patients sue doctors for malpractice because malpractice premiums will go up and doctors will leave the state, and there'll be no one to treat us."

• "Don't enforce ERISA rules against employers, because then companies will stop offering insurance, and we'll have more uninsured."

• "Don't punish crooked CEOs, because pretty soon we'll be unable to hire people to run our companies."

BS! A crime's a crime! A fraud's a fraud! If we don't punish them they become rampant in society. If we do punish them, society will reach a new equilibrium at a more honest level.