Special Report: Managed Care in 2011

Dear Member,

This special edition of the Bulletin focuses on the accomplishments achieved on your behalf in the managed care arena by the NCMS and the Physicians Advocacy Institute, a national organization in which the NCMS is actively involved.

Reimbursement issues are the number one frustration among physicians according to our member surveys. As we look back on 2011, the NCMS built a strong track record ensuring that health plans used fair business practices in their dealings with physicians. You’ll see from other stories appearing in this final Bulletin of 2011 that the NCMS devoted significant resources to these efforts.

I also want to highlight our work this year in the public sector. The NCMS was able to minimize the impact of the state’s revenue shortfall on the state Medicaid budget. We also worked successfully to resolve many issues between Palmetto GBA and the physicians and physician assistants who treat Medicare patients.

The NCMS Bulletin routinely reports on these successes throughout the year, and more information can be accessed at our website at https://www.compassionatecarenc.org/. Rest assured that in the year ahead the NCMS will continue to work on issues that affect your practice, the delivery of health care in North Carolina, and most importantly, the relationship you have with your patients.

On behalf of the staff and Board of Directors, I wish you a joyful and happy holiday season.

                                                                                     Robert W. Seligson, MBA, MA

                                                                                    EVP, CEO

                                                                                    President, Physicians Advocacy Institute

NCMS Managed Care Activity in 2011

Throughout 2011 the NCMS remained actively engaged with the health plans. We successfully addressed and resolved a variety of managed care issues. We reported these efforts in the Bulletin to keep you informed about how our work would affect your practices. Here is a sampling, of what the NCMS has accomplished:

DOI Sides with Medicine, Blocks Controversial BCBSNC Radiology Policy (12-9-11)

UHC Deploying a Revised Treatment Cost Estimator for Members in 2012 (12-2-11)

IPG Inks Agreement with BCBSNC to Provide Implantable Device Management (12-2-11)

“Heal the Claims Process” and PractEssentials: Resources to Help Cut Practice Costs (11-11-11)

Joint Complaint Filed Over BCBSNC Radiology Services Reimbursement Policy (10-28-11)

PAI Compliance Committee Convenes in Chicago (9-9-11)

Meeting with NCMS Prompts UnitedHealth Group to Revisit Many Details of Premium Designation Program (6-17-11)

Thomas/Love Settlement Agreement Expires; BCBSNC to Permanently Adopt Many Key Settlement Practices (6-3-11)

Blue Cross Blue Shield Launches “Let’s Talk Cost” (4-15-11)

UHC Extends Premium Designation Program Deadlines; Physicians Should Check Designations (3-25-11)

Delay Prompts UnitedHealthcare to Extend Deadline in Premium Designation Program (3-4-11)

Humana: HEDIS Reviews on Humana Medicare Advantage Members Begin in March (2-18-11)

State Health Plan to Seek Reimbursements from Ineligible Members, Not Physicians (1-21-11)

UHC Notifying MDS about Physician Profiling/Tiering Program; Doctors Have Limited Time to Seek Reconsideration of Information (1-14-11)

PAI: Physicians Reap More Than $2 Billon in Benefits from Settlement Successes

The NCMS has been actively involved with the Physicians Advocacy Institute (PAI) since it was formed in 2006 as a result of Multi-District Litigation (MDL) class action settlements against major national for-profit insurers. PAI has worked to guarantee compliance with the settlements and to develop projects and tolls that help guarantee the viability of physicians’ medical practices and the ability of physicians to deliver quality patient care.

Here is a summary of Physician Advocacy Institute activity on behalf of physicians:

Physicians have received more than $2 billion dollars in benefits from the settlement agreements reached with Aetna, CIGNA, Health Net, Humana, Anthem/Wellpoint, and many Blue Cross Blue Shield plans as a result of class action lawsuits brought against these insurers by the NCMS and 18 other state and county medical organizations and physician representatives.

For most physicians, the greatest benefit came from the business changes these insurers were required to implement under the settlement agreements, such as:

  • Paying claims promptly;
  • Separately recognizing and paying for modifiers 25 and 59;
  • Notifying physicians 90 days in advance of any material adverse changes; and
  • Limiting the time frame in which insurers could seek recovery of alleged overpayments.

      (Source: Physicians Advocacy Institute)

At the time the settlements were approved by the federal court (US District Court, Miami), the business changes were estimated to be $2 billion to physicians. Because Aetna, CIGNA, Health Net and Humana have committed to retain many of the business changes after the termination of their settlement agreements, this value will only continue to increase over time.

 Compliance Disputes Benefit Physicians

 Hundreds of physicians and several signatory medical societies, including the NCMS, have filed compliance disputes to ensure that insurers hold to their agreements. Since the inception of the compliance process in 2004, compliance disputes have benefited physicians by at least $22 million. The compliance process is overseen by PAI, which was founded in part to enforce the settlement agreements. PAI’s Board is comprised of the CEOs of many of the state and county medical associations which filed the initial lawsuits, including the NCMS. NCMS Executive Vice President, CEO Robert W. Seligson, MBA, MA, has served as an officer of the PAI since its inception, and currently serves as President.

NCMS Intervention in compliance disputes benefited physicians

  • An insurer sought recovery of $437,358.12 in alleged overpayments from a North Carolina family physician relating to claims over a four year period in violation of §7.22.  After NCMS filed a compliance dispute on his behalf, the insurer agreed to cease any efforts to collect alleged overpayments beyond the 18 months allowed by its settlement agreement, saving the practice at least $200,000.
  • An insurer paid a North Carolina emergency physicians’ practice $125,000 after it filed a compliance dispute alleging that the insurer’s EOB’s sent to patients did not accurately reflect patients’ responsibility for payment, in violation of §7.21.
  • An insurer withdrew a contract addendum which did not comply with its settlement agreement and issued a new addendum consistent with the settlement agreement after NCMS filed a compliance dispute showing that the original addendum did not provide physicians with sufficient advance notice of material adverse changes and fee schedule reductions in violation of the settlement agreement.
  • After a compliance dispute alleging that an insurer was not paying for the add-on codes for myocardial infusion and CAD mammography in violation of §7.20, North Carolina physicians submitting claims for reprocessing received $363,000.

PAI Claims Data Warehouse Evaluates What Happens to Physicians’ Claims

PAI has developed a business intelligence tool called MDEdge, which is used to analyze 837 claims data from all third party payors and 835 remittance forms from insurers indicating what has been paid. The tool can determine if payments to physicians are correct and if the insurers have applied code edits or made other inappropriate “adjustments” to the physician’s reimbursement. Physicians can learn more about this tool by contacting National Healthcare Exchange Services (NHXS) at: [email protected] or calling 888-466-1472. Click here to access an FAQ about MDEdge.

Click here to read more about how the NCMS has worked for you in addressing managed care payor issues.

For resources and more information about managed care, click here.


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