"One Cannot Measure What One Does Not Manage": Shaking Down Docs (Part XIII-j)

(Continuation of last week's post, "The Regulators are not your Friends")

From: Gilbert R (Academic PPO's Exec. Dir.) Date: April 14, 2009 10:02:10 AM EDT

It should come as no surprise that Medicare managed care plans underpay non-pars:

Medicare Advantage (Managed Care) Plans try taking advantage of physicians who are not participating (non par) with them. For example, when a patient perceives they are in urgent need of medical attention and they are either out of area or there's a dearth of appropriate practitioners available in network, the caring doc does the work and gets paid less than reasonable or expected.

Few of the Medicare Advantage Plans have provisions for out-of-network care, but this does not mean that their patients are any better at following the restricted network rules then are younger plan enrollees. Indeed, Medicare plan member often go to out-of-network providers for treatment and when this happens, federal law allows the out-of-network provider to demand payment, up to the amount it would have been paid if the patient had been in traditional Medicare.

However, most Medicare Advantage Plans make payment at their contracted rate, usually 75% and 87% of traditional Medicare. When challenged, often these plans will deny responsibility for higher rates. Moreover, they will count on provider ignorance or exhaustion from disputing for the practitioners to accept a meager offering as payment in full.

This unsavory practice is financially painful for any affected out-of-network physicians. Fortunately, the illegitimately underpaid practitioners can push the plan to do what is their lawful obligation. Here are the necessary steps to take:

• Step #1 Determine the amount of underpayment by researching the Medicare fee schedule for your services.

What to say: Identify the patient and the claim with copies of your bill and their EOB attached. Cite the law, advising them that under the Balance Budget Act, non-contracted providers are to be paid the traditional Medicare rate when treating Medicare plan members. Then, clarify that for you, no contract exists. Moreover, you never agreed to accept a low rate of payment on the claim. Demand action in 20 days. End with a representation that should there be no response in [specify what time frame], you will forward the letter to:

Robert Bersensen, MD

Director HCFA Center for Health Plans and Providers

7500 Security Blvd.

Baltimore, MD 21244

• CC: HCFA on your letter because while they will not actually intervene in a private payment dispute between a plan and a physician, they do want to know if contracted plans are underpaying providers.

• Step #2 Write to the plan. If you have been shortchanged, send, certified mail; return receipt requested, a copy of the bill for your services to the plans along with a letter demanding full payment. (If there was a health plan employee who was, in any way, involved in the arrangement for the care or the subsequent enquiries, address said letter to their attention.)• Step #3 When all else fails, involve the patient; advise them that they may be liable if their plan does not accept their responsibility.