Physician Patient

Archive for November, 2019

Up to their old games: Minnesota insurance companies are denying mental health claims

Wednesday, November 6th, 2019

Up to their old games?
Undeniably, denying claims is the managed care business model. “Captain may I” managed care prior authorizations and claims denials are the dominant health care rationing strategies of Minnesota insurance companies and third party administrators (TPA) contracted by self-funded corporations.
United Healthcare (which originated in Minnesota) is the reigning champion of these practices.
Claims denying is used extensively for managing mental health claims. That’s why mental health advocates pushed for mental health parity laws. However, the deal-breaking caveat for implementing state and federal mental health parity laws to expand coverage is this: Medical necessity is determined (defined and decided) by the managed care company itself, not by the patient’s health care “provider” (physician, psychologist, social worker, etc.), or an independent arbitrator, or most importantly by the consumer (patient and family). And the denials can occur before, during, or after treatment is provided.
I left employment as a mental health medical director at a large Minnesota PPO years ago because I couldn’t work for an enterprise that advertised and competed with other managed care companies touting its effectiveness in denying patients’ mental health claims.
How best to fight third party mental health claims denials? Stop contracting with third parties. Most Minnesota physicians are now employees and their organizations do the dirty work. Independent doctors can be paid by their patients. And patients themselves can get payments from their insurance companies.
Complaints and public pressure require tireless and Sisyphean efforts on the part of both doctors and patients. The managed care stone always rolls back on one; its corporate economic power and mass exponentially growing. When patients have skin in the game they will complain. And patients’ complaints matter most when they are reinforced by other patients and community mental health advocacy organization such as NAMI-Minnesota. Or if the rolling stone is an asteroid law suit involving lots of public money and taxpayers. [See the Westin case and MN AG Mike Hatch’s suit against BCBSM in 2001 http://news.minnesota.publicradio.org/features/200106/19_stawickie_bluecross/]
Uncollected accounts receivable in a private practice? The bigger they become the more the doctor is pushed into giving up her independent practice. That’s part of the UHC playbook as well.

Minnesota Independent Medical Practice and Consumer-directed Health Care Policy

Tuesday, November 5th, 2019

MPPA Meeting Wednesday October 23, 2019 at 6-8 PM in the conference room at Crutchfield Dermatology, Egan MN.

Those present: President Lee Beecher MD, Bob Geist MD (RWG), Lyle Swenson MD, Wayne Zuehlke CPA, Dave Feinwachs JD, PhD, Carl Burkland MD, Mark Holder MD, Carolyn McClain MD, Mike Ainslie MD, Neil Shah MD, Merlin Brown MD, Doug Smith MD, Matt Flanders, and Dave Racer.

The result was an excellent conference with quality presentations. As Dave Racer wrote, As one of the laymen in the room last night I’d call the gathering a great success. For what we learned about individual initiative, entrepreneurism, and hope. For being faced with stark realities as a result of the furtherance of factory medicine, for the love of practicing medicine heard around the table.” [As Dave noted, there may be no single fix for the medical system, but all the small things we do (the meeting was a good example) are aimed at a single goal: empowering American patients and families. That would be where American families are kings in a medical free-market place. A place where prices guide decisions on quantity and quality of services to buy, where everyone has money for medical care — whether from a wage, savings, or a safety-net program, and where insurance is for financial catastrophe, not for prepayment of care “promised” by colluding profiteering political-corporate cartel barons holding all the money—rwg] Please note: my comments are in [brackets]

 

Minutes of the May 16, 2019 meeting were circulated to all before the meeting.

 

1) Independent Practice, Challenges and Solutions was the focus of an outstanding meeting featuring four outstanding Minnesota physicians: MPPA Fellows: Doctors Doug Smith, Mark Holder, and Merlin Brown who were joined by Dr. Carolyn McClain. The discussion was led by MPPA President Dr. Lee Beecher www.leebeecher.com

 

Dr. Doug Smith https://www.oronofamilymedicine.com/ led-off the discussion by recounting his journey from a part-time to (currently) a full-time solo cash-only family practice. Doug’s practice model, he agreed, would be difficult for a newly minted medical specialty resident to jump into; Doug has the advantage of a long history in family practice gaining experience with patients earning a fine reputation in the community for which satisfied patients seek him out. [BTW, Dr. Smith was the originator of MinuteClinic, is a book author, an excellent speaker, and a member of the CCHF Wedge of Freedom https://www.cchfreedom.org/cchf.php/1183 ]

 

Dr. Mark Holder http://mperialhealth.com/physician/ recounted development of his growing and thriving solo family practice within a concierge (retainer fee) structure featuring a set monthly fee, open-ended as-needed clinic access, no co-pays or surprise billing to patients for his professional services, no insurance hassles for him, and (encouraged) acceptance of direct payments from a patient’s HSA.

 

Dr. Merlin Brown https://health.usnews.com/doctors/merlin-brown-137904, is a practicing internist (now in solo practice) who described creating SolarteHealth https://angel.co/company/solarte-health-1 , a new practice networking model for associated independent clinics (which are not necessarily cash-only) linked together by Solate as a TPA (Third Party Administrator) as an alternative to an insurance company and managed care. The Solarte TPA model is appealing to employers who are self-funded who want cost-effective alternatives to expensive and administratively driven HMOs and closed-panel provider networks. The typical employer client for Solarte is self-insured. The model has 2 tiers: Tier 1 is a group of cash practices with transparent fees to patients (posted prices) which is paid 100% by the employer (no co-pays or deductibles for employees!). Tier 2 includes a preferred provider organization (PPO) which in today’s market is needed to allow greater patient access to and choice of specialty care. Merlin hopes the PPO option will lose importance in the future as more physicians join up. The Solarte TPA model is proving to be attractive to employers and individual consumers (patients and families). Payments to clinics for equivalent medical services are up to 80% less than in the current commercial managed care medical market. [For those who are interested in this innovative concept of independent practice, contact Merlin Brown at http://www.solartehealth.com/ or 952-999-4049.

Dr. Carolyn McClain 

https://constellationmutual.com/bio/dr-carolyn-mcclain/

 

An ER doc and clinic leader, Carolyn reported on her recent trip to Washington DC (on her own dime) to scrutinize and meet with Minnesota policymakers about current legislative bills  ostensibly designed to eliminate or control “surprise billings” after the fact to unsuspecting patients. Who should control or arbitrate these unexpected bills from out-of-network anesthesiologists or other professionals? She explained that proposed legislation to curb surprise billing if enacted will empower insurance titans and private investment firms (PIFs) which are responsible for (exponentially) buying up remaining independent medical practices in the US.

Also, current legislative activity on surprise billing will accelerate the demise of independent medical practices. And the argument she heard from our policymakers is that large organizations are needed to control the independent medical practice outliers. Meanwhile, private investment firms (PIF) are investing in ever-larger insurance-provider controlling organizations. And PIFs are cashing in on bait and switch tactics used by healthcare investment oligopolies which as a business practice offer signing bonuses to independent physicians and clinics (bribes) followed by loss of their professional practice autonomy and incrementally lowering salaries contributing to physician burnout. Private investment firms bet on and profit from healthcare mergers and acquisitions which feed the big players. And “surprise billing arbitrations affect only for fees greater than $1,200. But since most medical procedure fees (e.g., routine radiology) are much lees than $1200 (for example, an ER visit). So there is no arbitration for most “surprise bills.”  Furthermore, the MCOs which control the clinician payments are using “surprise billings” as a Trojan horse issue to actually fix prices upwards to their advantage.

There is a better way: By usingbaseball-style” independent dispute arbitration (IDR) pegged at 80% of median prices determined through an independent database, such as the FAIR Health Database. Patients are taken out of the middle of disputes and physicians still retain some leverage in negotiations. [Is 80% detrimental price fixing for clinicians? Why not 100%—rwg] Apparently, a NY model does work. Will anything pass? PIFs don’t want any bill, but both Republicans and Democrats want to “fix” surprise billings. Carolyn found that lots of docs in DC are worried about the same issues for which she went to Washington.

One commentator asked, what happened to Anti-corporate practice of medicine laws? Dave Feinwachs noted that these laws are functionally dead, and quipped that this allows Republicans to laud Medicare Advantage (HMO) plans which are profit-driven to ration care for those > age 65 and Democrats to laud “single-payer” MCO cartels which are profit-driven to ration care for those < age 65.

2) Agenda. ACO mercenary manipulations and Pre-RX Bundled prices. [Rep Glenn Gruenhagen was not present at this meeting–rwg].

Bob Geist briefed everyone on a bill: to mandate ACO disclosure to enrollees and providers of payments contingent on the volume of referrals (aka “value pay”). This makes ACO-HMO corporations liable for lawsuits alleging delay and denial of care, if the clinicians are paid bonuses contingent on the volume of referrals (aka “value pay”). Disclosures required by this law may not be claimed as proprietary or trade secrets.

 

Bob then noted the MN House staff is writing a bill requiring the posting of Pre-treatment pricing of common bundled services for individuals (not populations) to halt “surprise” billings including contracted transparency for 50 common elective procedures (from complex heart surgery to OP colonoscopy) before services are delivered. We have an unbundled post-care billing problem. Hospitals are gaming the CMS transparency mandate. It doesn’t work—there are unusable endless coding prices, surprises! Dr. Brown noted that this is what’s going-on with independent practice pricing.

 

Bob then noted the Family Medical Account (FMA) Medicaid reform bill (HF 2873).

 

3) Reference-based Pricing (RBP).

 

Dave Racer gave us a brief update. He and Greg Datillio are publishing a book, Health Care 2020: Connecting the Dots. Apparently RBP does work elsewhere in the Us, but has not gotten going as yet in MN.

 

4) Next meeting to be announced.

 

Again, our thanks to Dr. Charles Crutchfield for his kindness in lending his office meeting room and for the wonderful help of his staff: Kelly and Allison.

 

Respectfully submitted,

 

Bob Geist, MPPA Secretary