The health care insurance
industry continues to move towards managed care despite growing public
resentment, increasing losses in the courtroom and declining profitability.
Consolidation and mergers have reduced the number of players, leaving the field
dominated by 10 or 11 companies that control 85% of the market. These entities
have the financial resources to significantly impede reform measures at the
national level, so no significant federal legislation is likely until after the
next election cycle.
Reports of abusive practices by managed care
organizations (MCO) continue to accumulate
- Retroactive denials
- Unjustified delays in payments of even undisputed
claims
- Limiting access and utilization by allowing provider networks
to deteriorate
- Excessive, intrusive and unreasonable documentation and review
requirements
- Closed formularies, slow adoption of innovations requiring
higher initial costs, etc.
MCOs argue that these reports are exaggerated, or are the
unintended growing pains of a repidly expanding industry and will decrease in
significance as the industry matures. However, this is of no comfort to those
of us who have lived under fire in the trenches of front line treatment for the
last few years. A real sense of combat fatigue among clinicians should not
blind us to signs that the battle may already be turning.
Encouraging
reports are now coming in mostly from the state, local and even theoffice
levels. State legislators have introduced and enacted hundreds of patient
protection measures, and Louisiana (like several other states) has enacted
parity legislation for selected mental illnesses. Louisiana also now requires
that MCO medical reviweers have a current Louisiana license. And state and
federal district courts in many jusristictions have seriously dented or
demolished the ERISA shield that had so thwarted efforts to regulate MCOs or
hold them accountable for bad behavior.
Thus it makes mroe sense now
than ever for us to virorously fight back. The individual practitioner can
effectivel advocate for patients by:
- Insisting that reviews for medical necessity be performed only
by Lousiana licensed psychiatrists. You may also request the name of the
reviewer, and that information should be passed on to the LPMA. Remind
companies that their refusal to comply could result in referral to state
authorities for criminal prosecution under the Louisiana Medical Practice
Act.
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- Appeal, appeal, appeal! Create a paper trail that demonstrates
your attempt to resolve the dispute internally. Use corroboration from clinical
colleagues or existing Utilization Review Committees to supprot your position.
Most of the time the offending MCO will eventually decide you are too much
trouble and will honor the claim.
- Refuse to play ball at all with the bad players. MCOs seeking
certain types of accreditation have to maintain a level of provider staffing to
meet these standards. Chances are that if they've been obnoxious to you,
they've been obnoxious to others, and as their provider ranks dwindle you may
have more clout than you think.
- Report bad MCO behavior directly to the employer. Often the
individuals who make the decisions about contracting for insurance also depend
on the offending MCO for their own care and that of their families.
- Inform your patients that they can report bad MCO behavior to
the Louisiana Insurance Commission. Inform them that they can complain to the
State Board of Medical Examiners about physician reviewers licensed inLouisiana
who make unjustified denials on the basis of inadequate
information.
- Inform your patients that there are lawyers out there who are
interested in representing those who have been defrauded by insurance companies
acting in bad faith. Pass on the names of reputable attorneys involved in such
cases to the LPMA so that we can pass them on to others.
- Ask if the offending MCO is accredited by the National
Committee for Quality Assurance (NCQA). Thi sorganization has emerged as the
most widely accepted accreditation agency for MCOs. Familarize yourself with
the NCQA standards (www.ncqa.org) and tell them you will report them for
violations.
Collectively we can advocate for our patients by:
- Continuing our support for legislation at the state level to
see that those responsible for bad decisions are actually held accountable for
those decisions.
- Disseminate information about abusive MCO practices to consumer
advocacy groups and the press.
- Advocate within our professional organizations for an
aggressive public relations counter-offensive to the misinformation spread by
MCO industry lobbying groups
- Join our efforts with other groups to initiate legal class
action or corrupt practices lawsuits against companies that systematically
mislead or defraud their customers.
The war we are waging does not turn on a single battle, and the
latest signs definitely point to victories to come, provided that we continue
to resist, make good use of our allies and do our part for those who turn to us
for help.
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