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Be aware of ‘gotcha’ clauses in managed care contracts
CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.
To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.
“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”
One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.
“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”
Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.
Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.
The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.
“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.
Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.
Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.
To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.
Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.
The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.
“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.
On Twitter @legal_med
CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.
To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.
“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”
One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.
“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”
Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.
Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.
The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.
“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.
Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.
Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.
To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.
Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.
The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.
“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.
On Twitter @legal_med
CHICAGO – Too often, physicians sign managed care contracts without negotiating or truly understanding all the terms. The complex clauses – or lack thereof – can come back to bite doctors in the form of delayed payments, sudden policy changes, and termination woes, health law attorney Mark S. Kopson warned at conference held by the American Bar Association.
To avoid these unwelcome surprises, prepare for contract discussions well before the conversation starts, Mr. Kopson advised.
“Don’t go into any negotiation unless you know two things. The first is what your starting position will be and, equally if not more important, is what is your ultimate line in the sand?” said Mr. Kopson, who practices in Bloomfield Hills, Mich. “If you go in there not knowing those answers, you’re liable to give away the store or not get what you really need.”
One major “gotcha” is an insurer that does not reveal upfront that it is not the actual payer, Mr. Kopson said. Some national companies that enter into contracts with doctors are basically network aggregators that negotiate price discounts but then sell the network to the health insurance marketplace, he explained. Physicians later realize their contract states that the company is not responsible for paying claims and that the doctor does not have a contract directly with the payer.
“This is a really big issue that I’ve been seeing more and more frequently,” Mr. Kopson said at the meeting. “If you don’t have a direct contract with the payer, you have the possibility of not being able to force payment obligations against the responsible party.”
Specify in your contract that the plan must require the payer to pay, he said. That way, if a payer fails to pay, the plan has breached its contract obligation.
Contract terms that involve medical necessity also can lead to frustration if not properly negotiated. In some cases, the fine print states that medical necessity will be determined by the plan’s medical director or otherwise will be ultimately decided by the payer. Instead, include language specifying that a treating physician’s professional opinion will be entitled to great deference if medical necessity comes into question, Mr. Kopson said.
The process surrounding clean claims is often overlooked by physicians during contract negotiations, he added. The “gotcha” occurs when a plan retains full control over how contested claims are handled.
“If you don’t adequately address this in the contract, you wind up with the payer taking multiple bites of the apple,” Mr. Kopson said.
Make sure to clarify parameters for how long insurers have to request additional information about a claim and whether they must pay a portion of the claim that is being contested, he advised. Include a firm time line of when payers must complete their review and address payment after the requested information is provided.
Another critical issue: changes to the contract. In some cases, doctors enter into a contract with a plan and then the plan decides some details aren’t working out and makes changes. The physician later learns that the contract language allowed the plan to make unilateral changes. In other instances, a plan institutes new products and doctors learn that they had only a certain timeframe to opt out.
To avoid these situations, specify during contract negotiations that policies in conflict with the contract are prohibited, that contract changes can only be made bilaterally, and that unless you directly opt-in to new products, you will not participate.
Mr. Kopson encouraged physicians to have a solid exit strategy in their contracts and to ensure terms regarding contract termination are clearly understood. Clearly defined criteria around “cause” for termination are imperative, he said. Additionally, if a plan alleges a termination breach, require it to send a written notice to a specific person/title and ensure that the notice also is provided to counsel.
The bottom line: To avoid trouble later, strongly negotiate at the start of a managed care contract, Mr. Kopson said.
“If you don’t ask, if you don’t negotiate it in there, you’re not going to have that weapon,” he said.
On Twitter @legal_med
EXPERT ANALYSIS FROM THE PHYSICIANS LEGAL ISSUES CONFERENCE
VIDEO: How should you respond to a possible privacy breach?
CHICAGO – Overreact, don’t underreact, when it comes to possible health care privacy breaches, attorney Clinton Mikel advised at a conference held by the American Bar Association.
The actions that physicians take immediately following a potential data exposure will significantly impact how the Health and Human Services Department’s Office for Civil Rights (OCR) responds to the incident and whether physicians face penalties, said Mr. Mikel, who specializes in the Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws.
In an interview at the conference, Mr. Mikel, who practices law in Southfield, Mich., discussed common misconceptions that physicians have about privacy breaches and the best ways in which to respond internally to possible exposures. He also offered guidance on the top mistakes to avoid when confronted with possible security breaches and shared perspective on how the OCR might address such issues in the future.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
CHICAGO – Overreact, don’t underreact, when it comes to possible health care privacy breaches, attorney Clinton Mikel advised at a conference held by the American Bar Association.
The actions that physicians take immediately following a potential data exposure will significantly impact how the Health and Human Services Department’s Office for Civil Rights (OCR) responds to the incident and whether physicians face penalties, said Mr. Mikel, who specializes in the Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws.
In an interview at the conference, Mr. Mikel, who practices law in Southfield, Mich., discussed common misconceptions that physicians have about privacy breaches and the best ways in which to respond internally to possible exposures. He also offered guidance on the top mistakes to avoid when confronted with possible security breaches and shared perspective on how the OCR might address such issues in the future.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
CHICAGO – Overreact, don’t underreact, when it comes to possible health care privacy breaches, attorney Clinton Mikel advised at a conference held by the American Bar Association.
The actions that physicians take immediately following a potential data exposure will significantly impact how the Health and Human Services Department’s Office for Civil Rights (OCR) responds to the incident and whether physicians face penalties, said Mr. Mikel, who specializes in the Health Insurance Portability and Accountability Act (HIPAA) and state privacy laws.
In an interview at the conference, Mr. Mikel, who practices law in Southfield, Mich., discussed common misconceptions that physicians have about privacy breaches and the best ways in which to respond internally to possible exposures. He also offered guidance on the top mistakes to avoid when confronted with possible security breaches and shared perspective on how the OCR might address such issues in the future.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
EXPERT ANALYSIS FROM THE PHYSICIANS LEGAL ISSUES CONFERENCE
ABIM changes exam score report, updates MOC exam blueprint
The American Board of Internal Medicine rolled out changes to its Maintenance of Certification program, including updates to its exam outline and score report, after more input from the internal medicine community.
Starting with spring 2015 exams, doctors will receive enhanced score reports with more performance details, according to a June 9 announcement by ABIM. The board has also updated its internal medicine MOC blueprint – the exam content outline – to ensure that the exam reflects how internists are practicing today and to provide more detailed explanations of topics that may be included in the exam.
The changes are positive and reflect the concerns that physicians have long expressed about the shortcomings of the past MOC process, said Dr. Wayne J. Riley, president of the American College of Physicians and a clinical professor of medicine at Vanderbilt University in Nashville, Tenn.
“This new and improved examination blueprint addresses the strong concerns that recertifiers have voiced about the inadequacy of the previous version,” Dr. Riley said in an interview. “It is a key first step in ultimately reforming and/or replacing the secure examination.”
Dr. Richard J. Baron, ABIM president and CEO, said both initiatives reflect ABIM’s efforts to listen to physicians and engage the internal medicine community in the design of ABIM programs.
“The updates to the score report and internal medicine MOC blueprint are early evidence of ABIM’s ongoing commitment to ensure that our resources are relevant to physicians working to keep their knowledge current in the rapidly changing field of medicine,” Dr. Baron said in a statement. “Many other efforts of this kind are planned as we continue to work with physicians to design ABIM’s programs.”
As part of the enhanced score report, examinees will receive information in a new, electronic format that includes a visual presentation of results, more detailed feedback about missed questions, and links to supplemental data.
The revised score report format was created in collaboration with ABIM board-certified physicians across several specialties through focus groups, a survey, and interviews, ABIM stated in its release. Dr. Riley said the ACP contributed to the changes through suggestions and input from its education division.
Meanwhile, the updated blueprint will be implemented starting with the fall 2015 internal medicine MOC exam.
The blueprint now includes a greater level of detail, with a task breakdown in addition to topics covered, and is color coded to indicate how specific combinations of topics and tasks are prioritized for selecting MOC exam questions, according to ABIM.
Most exam questions will address content rated as high-importance, while some questions will address content rated as medium-importance. No questions will address content rated as low-importance.
In addition, ABIM is implementing a process that will give all ABIM board-certified physicians the opportunity to participate in an annual blueprint review. The process will be introduced for some specialties by the end of 2015, and will be rolled out across all ABIM specialties over the next 2 years.
ABIM turned to practicing physicians to help determine which topics to emphasize in the updated internal medicine MOC blueprint, said Dr. Nick Fitterman, chair of ABIM’s Internal Medicine Board Exam Committee.
“As the practice of medicine changes, ABIM must work closely with the physician community to continuously ensure that our exams reflect foundational knowledge that doctors in practice today need to serve their patients,” Dr. Fitterman said in a statement.
The American College of Cardiology welcomed the closer collaboration with physicians.
“The American College of Cardiology recognizes that the American Board of Internal Medicine has heard concerns from the medical community about the relevance of its Maintenance of Certification process to patient care,” said ACC President Kim Allan Williams Sr., M.D. “It is important that physicians are continually engaged in making Maintenance of Certification a valuable and relevant process to their practice of medicine.”
However, “the ACC is exploring options for a certification process that ensures professionalism in the constantly changing field of medicine,” Dr. Williams added. “Maintenance of certification should not be overly cumbersome or excessively costly in terms of time or money. In the end, we must remember what is most important – offering quality care to our patients.”
The new changes follow a February announcement by ABIM apologizing to doctors for an MOC program that “clearly got it wrong.”
ABIM pledged to make the program more consistent with physicians’ practice and values. Among the immediate changes are updates to its internal medicine exam, suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years, and setting MOC enrollment fees at or below 2014 levels through at least 2017.
On Twitter@legal_med
The American Board of Internal Medicine rolled out changes to its Maintenance of Certification program, including updates to its exam outline and score report, after more input from the internal medicine community.
Starting with spring 2015 exams, doctors will receive enhanced score reports with more performance details, according to a June 9 announcement by ABIM. The board has also updated its internal medicine MOC blueprint – the exam content outline – to ensure that the exam reflects how internists are practicing today and to provide more detailed explanations of topics that may be included in the exam.
The changes are positive and reflect the concerns that physicians have long expressed about the shortcomings of the past MOC process, said Dr. Wayne J. Riley, president of the American College of Physicians and a clinical professor of medicine at Vanderbilt University in Nashville, Tenn.
“This new and improved examination blueprint addresses the strong concerns that recertifiers have voiced about the inadequacy of the previous version,” Dr. Riley said in an interview. “It is a key first step in ultimately reforming and/or replacing the secure examination.”
Dr. Richard J. Baron, ABIM president and CEO, said both initiatives reflect ABIM’s efforts to listen to physicians and engage the internal medicine community in the design of ABIM programs.
“The updates to the score report and internal medicine MOC blueprint are early evidence of ABIM’s ongoing commitment to ensure that our resources are relevant to physicians working to keep their knowledge current in the rapidly changing field of medicine,” Dr. Baron said in a statement. “Many other efforts of this kind are planned as we continue to work with physicians to design ABIM’s programs.”
As part of the enhanced score report, examinees will receive information in a new, electronic format that includes a visual presentation of results, more detailed feedback about missed questions, and links to supplemental data.
The revised score report format was created in collaboration with ABIM board-certified physicians across several specialties through focus groups, a survey, and interviews, ABIM stated in its release. Dr. Riley said the ACP contributed to the changes through suggestions and input from its education division.
Meanwhile, the updated blueprint will be implemented starting with the fall 2015 internal medicine MOC exam.
The blueprint now includes a greater level of detail, with a task breakdown in addition to topics covered, and is color coded to indicate how specific combinations of topics and tasks are prioritized for selecting MOC exam questions, according to ABIM.
Most exam questions will address content rated as high-importance, while some questions will address content rated as medium-importance. No questions will address content rated as low-importance.
In addition, ABIM is implementing a process that will give all ABIM board-certified physicians the opportunity to participate in an annual blueprint review. The process will be introduced for some specialties by the end of 2015, and will be rolled out across all ABIM specialties over the next 2 years.
ABIM turned to practicing physicians to help determine which topics to emphasize in the updated internal medicine MOC blueprint, said Dr. Nick Fitterman, chair of ABIM’s Internal Medicine Board Exam Committee.
“As the practice of medicine changes, ABIM must work closely with the physician community to continuously ensure that our exams reflect foundational knowledge that doctors in practice today need to serve their patients,” Dr. Fitterman said in a statement.
The American College of Cardiology welcomed the closer collaboration with physicians.
“The American College of Cardiology recognizes that the American Board of Internal Medicine has heard concerns from the medical community about the relevance of its Maintenance of Certification process to patient care,” said ACC President Kim Allan Williams Sr., M.D. “It is important that physicians are continually engaged in making Maintenance of Certification a valuable and relevant process to their practice of medicine.”
However, “the ACC is exploring options for a certification process that ensures professionalism in the constantly changing field of medicine,” Dr. Williams added. “Maintenance of certification should not be overly cumbersome or excessively costly in terms of time or money. In the end, we must remember what is most important – offering quality care to our patients.”
The new changes follow a February announcement by ABIM apologizing to doctors for an MOC program that “clearly got it wrong.”
ABIM pledged to make the program more consistent with physicians’ practice and values. Among the immediate changes are updates to its internal medicine exam, suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years, and setting MOC enrollment fees at or below 2014 levels through at least 2017.
On Twitter@legal_med
The American Board of Internal Medicine rolled out changes to its Maintenance of Certification program, including updates to its exam outline and score report, after more input from the internal medicine community.
Starting with spring 2015 exams, doctors will receive enhanced score reports with more performance details, according to a June 9 announcement by ABIM. The board has also updated its internal medicine MOC blueprint – the exam content outline – to ensure that the exam reflects how internists are practicing today and to provide more detailed explanations of topics that may be included in the exam.
The changes are positive and reflect the concerns that physicians have long expressed about the shortcomings of the past MOC process, said Dr. Wayne J. Riley, president of the American College of Physicians and a clinical professor of medicine at Vanderbilt University in Nashville, Tenn.
“This new and improved examination blueprint addresses the strong concerns that recertifiers have voiced about the inadequacy of the previous version,” Dr. Riley said in an interview. “It is a key first step in ultimately reforming and/or replacing the secure examination.”
Dr. Richard J. Baron, ABIM president and CEO, said both initiatives reflect ABIM’s efforts to listen to physicians and engage the internal medicine community in the design of ABIM programs.
“The updates to the score report and internal medicine MOC blueprint are early evidence of ABIM’s ongoing commitment to ensure that our resources are relevant to physicians working to keep their knowledge current in the rapidly changing field of medicine,” Dr. Baron said in a statement. “Many other efforts of this kind are planned as we continue to work with physicians to design ABIM’s programs.”
As part of the enhanced score report, examinees will receive information in a new, electronic format that includes a visual presentation of results, more detailed feedback about missed questions, and links to supplemental data.
The revised score report format was created in collaboration with ABIM board-certified physicians across several specialties through focus groups, a survey, and interviews, ABIM stated in its release. Dr. Riley said the ACP contributed to the changes through suggestions and input from its education division.
Meanwhile, the updated blueprint will be implemented starting with the fall 2015 internal medicine MOC exam.
The blueprint now includes a greater level of detail, with a task breakdown in addition to topics covered, and is color coded to indicate how specific combinations of topics and tasks are prioritized for selecting MOC exam questions, according to ABIM.
Most exam questions will address content rated as high-importance, while some questions will address content rated as medium-importance. No questions will address content rated as low-importance.
In addition, ABIM is implementing a process that will give all ABIM board-certified physicians the opportunity to participate in an annual blueprint review. The process will be introduced for some specialties by the end of 2015, and will be rolled out across all ABIM specialties over the next 2 years.
ABIM turned to practicing physicians to help determine which topics to emphasize in the updated internal medicine MOC blueprint, said Dr. Nick Fitterman, chair of ABIM’s Internal Medicine Board Exam Committee.
“As the practice of medicine changes, ABIM must work closely with the physician community to continuously ensure that our exams reflect foundational knowledge that doctors in practice today need to serve their patients,” Dr. Fitterman said in a statement.
The American College of Cardiology welcomed the closer collaboration with physicians.
“The American College of Cardiology recognizes that the American Board of Internal Medicine has heard concerns from the medical community about the relevance of its Maintenance of Certification process to patient care,” said ACC President Kim Allan Williams Sr., M.D. “It is important that physicians are continually engaged in making Maintenance of Certification a valuable and relevant process to their practice of medicine.”
However, “the ACC is exploring options for a certification process that ensures professionalism in the constantly changing field of medicine,” Dr. Williams added. “Maintenance of certification should not be overly cumbersome or excessively costly in terms of time or money. In the end, we must remember what is most important – offering quality care to our patients.”
The new changes follow a February announcement by ABIM apologizing to doctors for an MOC program that “clearly got it wrong.”
ABIM pledged to make the program more consistent with physicians’ practice and values. Among the immediate changes are updates to its internal medicine exam, suspension of the practice assessment, patient voice, and patient safety requirements for at least 2 years, and setting MOC enrollment fees at or below 2014 levels through at least 2017.
On Twitter@legal_med
User errors are top reason for EHR-related malpractice claims
User error, such as incorrect data input, contributes to the majority of medical malpractice claims that involve electronic health records.
Of 97 EHR-related malpractice claims that closed from January 2007 to June 2014, 64% involved user errors, while 42% related to system factors, according to an analysis from national medical liability insurer The Doctors Company. (Numbers do not add up to 100% because some claims contained more than one contributing factor.)
The most common user errors included incorrect information in the EHR (16%), hybrid health records/EHR conversion (15%), and problems regarding prepopulating/copy and pasting (13%). Less common user factors involved training/education, EHR alert issue or fatigue, and workarounds, according to the report.
EHR-related malpractice claims appear to be on the rise, said Dr. David B. Troxel, medical director for The Doctors Company. Of the 97 EHR-related claims, 26 claims closed in the first half of 2014, compared with 28 claims that closed in 2013, 22 that closed in 2012, 19 that closed in 2011, and 2 that closed between 2007 and 2010.
“Electronic health records provide benefits but also create risks that can contribute to medical malpractice claims,” Dr. Troxel said in an interview. “Their widespread use is too recent to tell whether the benefits will outweigh the risks and result in a decrease in adverse patient events. In the meantime, I believe we will see an increase in claims over the next few years in which EHRs are a contributing factor.”
Of system-related EHR claims, 10% involved system design failures. Electronic systems/technology failures contributed to 9% of cases, and 7% involved a lack of EHR alert or alarm/decision support. Other system-related claims were attributed to inappropriate data routing, insufficient scope/area for documentation, and fragmentation.
In one such case examined, a plaintiff claimed the lack of a medication risk alert led to the death of a dialysis patient. The patient was transferred to a skilled nursing facility with an active hospital transfer order for enoxaparin. A physician evaluated the patient upon admission but made no comment about the enoxaparin order. During the first dialysis treatment, there was active bleeding at the fistula site, but a nurse did not inform the physician. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient later died.
As for practice area, internal medicine subspecialists – including cardiologists, hospitalists, oncologists, and gastroenterologists – were the most likely to see EHR-related claims at 20%. Primary care physicians – family physicians and general internists – faced claims in 16% of cases, while ob.gyns. were accused in 15% of cases. Other cases involved claims against surgeons (14%), nurses (7%), radiologists (5%), anesthesiologists, (4%), general surgeons (4%), pediatricians (2%), emergency medicine physicians (2%), psychiatrists (2%), orthopedists (2%), and pathologists (1%). Other claims were against nonphysician providers.
Among all EHR-related claims, the top allegations made were diagnosis failure and medication error, including allegedly ordering the wrong medication, prescribing an incorrect dosage, or improper medication management.
User error, such as incorrect data input, contributes to the majority of medical malpractice claims that involve electronic health records.
Of 97 EHR-related malpractice claims that closed from January 2007 to June 2014, 64% involved user errors, while 42% related to system factors, according to an analysis from national medical liability insurer The Doctors Company. (Numbers do not add up to 100% because some claims contained more than one contributing factor.)
The most common user errors included incorrect information in the EHR (16%), hybrid health records/EHR conversion (15%), and problems regarding prepopulating/copy and pasting (13%). Less common user factors involved training/education, EHR alert issue or fatigue, and workarounds, according to the report.
EHR-related malpractice claims appear to be on the rise, said Dr. David B. Troxel, medical director for The Doctors Company. Of the 97 EHR-related claims, 26 claims closed in the first half of 2014, compared with 28 claims that closed in 2013, 22 that closed in 2012, 19 that closed in 2011, and 2 that closed between 2007 and 2010.
“Electronic health records provide benefits but also create risks that can contribute to medical malpractice claims,” Dr. Troxel said in an interview. “Their widespread use is too recent to tell whether the benefits will outweigh the risks and result in a decrease in adverse patient events. In the meantime, I believe we will see an increase in claims over the next few years in which EHRs are a contributing factor.”
Of system-related EHR claims, 10% involved system design failures. Electronic systems/technology failures contributed to 9% of cases, and 7% involved a lack of EHR alert or alarm/decision support. Other system-related claims were attributed to inappropriate data routing, insufficient scope/area for documentation, and fragmentation.
In one such case examined, a plaintiff claimed the lack of a medication risk alert led to the death of a dialysis patient. The patient was transferred to a skilled nursing facility with an active hospital transfer order for enoxaparin. A physician evaluated the patient upon admission but made no comment about the enoxaparin order. During the first dialysis treatment, there was active bleeding at the fistula site, but a nurse did not inform the physician. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient later died.
As for practice area, internal medicine subspecialists – including cardiologists, hospitalists, oncologists, and gastroenterologists – were the most likely to see EHR-related claims at 20%. Primary care physicians – family physicians and general internists – faced claims in 16% of cases, while ob.gyns. were accused in 15% of cases. Other cases involved claims against surgeons (14%), nurses (7%), radiologists (5%), anesthesiologists, (4%), general surgeons (4%), pediatricians (2%), emergency medicine physicians (2%), psychiatrists (2%), orthopedists (2%), and pathologists (1%). Other claims were against nonphysician providers.
Among all EHR-related claims, the top allegations made were diagnosis failure and medication error, including allegedly ordering the wrong medication, prescribing an incorrect dosage, or improper medication management.
User error, such as incorrect data input, contributes to the majority of medical malpractice claims that involve electronic health records.
Of 97 EHR-related malpractice claims that closed from January 2007 to June 2014, 64% involved user errors, while 42% related to system factors, according to an analysis from national medical liability insurer The Doctors Company. (Numbers do not add up to 100% because some claims contained more than one contributing factor.)
The most common user errors included incorrect information in the EHR (16%), hybrid health records/EHR conversion (15%), and problems regarding prepopulating/copy and pasting (13%). Less common user factors involved training/education, EHR alert issue or fatigue, and workarounds, according to the report.
EHR-related malpractice claims appear to be on the rise, said Dr. David B. Troxel, medical director for The Doctors Company. Of the 97 EHR-related claims, 26 claims closed in the first half of 2014, compared with 28 claims that closed in 2013, 22 that closed in 2012, 19 that closed in 2011, and 2 that closed between 2007 and 2010.
“Electronic health records provide benefits but also create risks that can contribute to medical malpractice claims,” Dr. Troxel said in an interview. “Their widespread use is too recent to tell whether the benefits will outweigh the risks and result in a decrease in adverse patient events. In the meantime, I believe we will see an increase in claims over the next few years in which EHRs are a contributing factor.”
Of system-related EHR claims, 10% involved system design failures. Electronic systems/technology failures contributed to 9% of cases, and 7% involved a lack of EHR alert or alarm/decision support. Other system-related claims were attributed to inappropriate data routing, insufficient scope/area for documentation, and fragmentation.
In one such case examined, a plaintiff claimed the lack of a medication risk alert led to the death of a dialysis patient. The patient was transferred to a skilled nursing facility with an active hospital transfer order for enoxaparin. A physician evaluated the patient upon admission but made no comment about the enoxaparin order. During the first dialysis treatment, there was active bleeding at the fistula site, but a nurse did not inform the physician. During the second dialysis treatment, there was uncontrolled bleeding from the fistula, and the patient later died.
As for practice area, internal medicine subspecialists – including cardiologists, hospitalists, oncologists, and gastroenterologists – were the most likely to see EHR-related claims at 20%. Primary care physicians – family physicians and general internists – faced claims in 16% of cases, while ob.gyns. were accused in 15% of cases. Other cases involved claims against surgeons (14%), nurses (7%), radiologists (5%), anesthesiologists, (4%), general surgeons (4%), pediatricians (2%), emergency medicine physicians (2%), psychiatrists (2%), orthopedists (2%), and pathologists (1%). Other claims were against nonphysician providers.
Among all EHR-related claims, the top allegations made were diagnosis failure and medication error, including allegedly ordering the wrong medication, prescribing an incorrect dosage, or improper medication management.
VIDEO: Can women physicians have it all? Absolutely, says AMWA past president
CHICAGO – Can women physicians succeed professionally while also meeting their personal goals?
Absolutely, says Dr. Farzanna Haffizulla, immediate past president of the American Medical Women’s Association and founder of a concierge practice in Davie, Fla.
While women physicians face challenges during every stage of their training and career, they should never give up personal goals for professional ambitions, or vice versa, Dr. Haffizulla said at the annual meeting of the American Medical Women’s Association.
Women doctors can meet dual objectives through strong organization, dedicated support systems, and steady determination, said Dr. Haffizulla, a nationally recognized speaker on work/life balance who has authored two books on the subject and runs the work/life balance website www.BusyMomMD.com.
In this video, Dr. Haffizulla shares her personal story of raising a family while also meeting her professional aspirations. She offers guidance and wisdom for other women physicians about how they can achieve a healthy work/life balance and remain fulfilled in all arenas.
CHICAGO – Can women physicians succeed professionally while also meeting their personal goals?
Absolutely, says Dr. Farzanna Haffizulla, immediate past president of the American Medical Women’s Association and founder of a concierge practice in Davie, Fla.
While women physicians face challenges during every stage of their training and career, they should never give up personal goals for professional ambitions, or vice versa, Dr. Haffizulla said at the annual meeting of the American Medical Women’s Association.
Women doctors can meet dual objectives through strong organization, dedicated support systems, and steady determination, said Dr. Haffizulla, a nationally recognized speaker on work/life balance who has authored two books on the subject and runs the work/life balance website www.BusyMomMD.com.
In this video, Dr. Haffizulla shares her personal story of raising a family while also meeting her professional aspirations. She offers guidance and wisdom for other women physicians about how they can achieve a healthy work/life balance and remain fulfilled in all arenas.
CHICAGO – Can women physicians succeed professionally while also meeting their personal goals?
Absolutely, says Dr. Farzanna Haffizulla, immediate past president of the American Medical Women’s Association and founder of a concierge practice in Davie, Fla.
While women physicians face challenges during every stage of their training and career, they should never give up personal goals for professional ambitions, or vice versa, Dr. Haffizulla said at the annual meeting of the American Medical Women’s Association.
Women doctors can meet dual objectives through strong organization, dedicated support systems, and steady determination, said Dr. Haffizulla, a nationally recognized speaker on work/life balance who has authored two books on the subject and runs the work/life balance website www.BusyMomMD.com.
In this video, Dr. Haffizulla shares her personal story of raising a family while also meeting her professional aspirations. She offers guidance and wisdom for other women physicians about how they can achieve a healthy work/life balance and remain fulfilled in all arenas.
EXPERT ANALYSIS FROM THE AMWA ANNUAL MEETING
GAO questions CMS reliance on RUC to set Medicare pay rates
A government watchdog report suggests that the Centers for Medicare & Medicaid Services may be setting Medicare payment rates inaccurately based on biased recommendations from its panel of physician experts.
The Government Accountability Office (GAO) questions the transparency of the CMS’ rate calculation process and suggests that members of the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) have conflicts of interest that affect their ability to fairly value physician services, according to a report published May 21.
The GAO report recommends that the CMS better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. The CMS also should develop a plan for using funds appropriated for the collection and use of information on physicians’ services in the determination of relative values, the report stated.
In response, the American Medical Association defended the expertise and objectivity of the RUC, stressing that there is no substitute for input from experienced physicians regarding the time and resources that go into medical services.
“The RUC’s valuable expertise is balanced with the oversight of government officials who have the final say,” an AMA spokesperson said in an interview. “When CMS’ initial efforts to identify potentially misvalued services were unable to obtain reliable data from government contractors, physicians on the RUC took on this important task. When gauging how much time and resources go into one medical service compared with another, no one knows more about what is involved in providing services to Medicare patients than the physicians who care for them.”
Dr. Robert L. Wergin, president of the American Academy of Family Physicians (AAFP) said the GAO report findings are consistent with previous concerns raised by the AAFP about the RUC.
“We have advocated for more transparency” in the past, Dr. Wergin said in an interview. “We have requested that the RUC expose the survey process, and we’ve also given input that we improve it [and] make it more accurate. Adding transparency to the process might be a way to improve it.”
In its review, the GAO – a nonpartisan investigational agency of Congress – cited several weaknesses in the data collected by the RUC, including that some RUC survey data had low response rates, a low total number of responses, and large ranges in responses.
For example, the GAO found that the median number of responses to surveys for payment year 2015 was 52 but the median response rate was only 2%, and that 23 of the 231 surveys had under 30 respondents.
The report also questions the transparency of the CMS process for establishing relative values. Although the CMS states that it complies with statutory requirements to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews, according to the GAO report.
The CMS also does not publish the potentially misvalued services identified by the RUC, so stakeholders are unaware that these services will be reviewed and payment rates for these services may change.
The report found that the CMS provides some information about its process in its rule-making but does not document the methods used to review specific RUC recommendations. For example, the CMS does not document which resources were considered during its review of RUC recommendations for specific services. The GAO report said the CMS relies too heavily on RUC recommendations when establishing relative values.
“GAO found that, in the majority of cases, CMS accepts the RUC’s recommendations, and participation by other stakeholders is limited,” the report authors said. “Given the process- and data-related weaknesses associated with the RUC’s recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.”
The AMA argued that the GAO report should have better acknowledged the difficulty in obtaining data on services that are infrequently performed. For example, 80% of services paid with work valuation on the Medicare physician payment schedule have fewer than 10,000 Medicare claims per year, the association noted.
“A service performed 10,000 times per year, is done, on average, less than once per day in any state,” the AMA spokesperson said. “It would be nearly impossible to do accurate direct observation or time/motion studies to collect time data on these low volume services. The survey methodology, followed by rigorous cross-specialty RUC review, is the best way to accomplish this data collection.”
The current GAO report is far from the first to criticize the RUC. The AAFP has long argued that the RUC should include more family physicians, health plans, consumers, employers, and health care economists on its panel. In 2012, the committee added another seat for geriatric medicine and another rotating primary care seat.
In an interview, Dr. Wergin said these additions helped, but that the AAFP would like to see at least one more primary care slot, as well as slots for other stakeholders. In a January 2014 letter, the AAFP called on the CMS to correct what the AAFP referred to as “a disturbing trend seen in the recommendations of RUC.” Specifically, the AAFP urged the CMS to address undervalued services, such as office-based evaluation and management (E/M) codes.
The Medicare Payment Advisory Commission (MedPAC), an independent advisory commission to Congress, has also issued several reports questioning the effectiveness of the RUC, including a 2011 white paper that expressed skepticism about the way in which data is collected by the panel. In 2013, MedPAC executive director Mark E. Miller, in testimony before the Senate Finance Committee, criticized how the RUC operated.
In the last Congress, Rep. Jim McDermott (D-Wash.), ranking member of the Ways and Means Committee’s Subcommittee on Health, introduced the Accuracy in Medicare Physician Payment Act of 2013, which would supplement the work of RUC by establishing an expert panel within Medicare to oversee the valuation of physician services and to help correct distortions in the physician fee schedule. The bill was not considered by the House.
On Twitter @legal_med
A government watchdog report suggests that the Centers for Medicare & Medicaid Services may be setting Medicare payment rates inaccurately based on biased recommendations from its panel of physician experts.
The Government Accountability Office (GAO) questions the transparency of the CMS’ rate calculation process and suggests that members of the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) have conflicts of interest that affect their ability to fairly value physician services, according to a report published May 21.
The GAO report recommends that the CMS better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. The CMS also should develop a plan for using funds appropriated for the collection and use of information on physicians’ services in the determination of relative values, the report stated.
In response, the American Medical Association defended the expertise and objectivity of the RUC, stressing that there is no substitute for input from experienced physicians regarding the time and resources that go into medical services.
“The RUC’s valuable expertise is balanced with the oversight of government officials who have the final say,” an AMA spokesperson said in an interview. “When CMS’ initial efforts to identify potentially misvalued services were unable to obtain reliable data from government contractors, physicians on the RUC took on this important task. When gauging how much time and resources go into one medical service compared with another, no one knows more about what is involved in providing services to Medicare patients than the physicians who care for them.”
Dr. Robert L. Wergin, president of the American Academy of Family Physicians (AAFP) said the GAO report findings are consistent with previous concerns raised by the AAFP about the RUC.
“We have advocated for more transparency” in the past, Dr. Wergin said in an interview. “We have requested that the RUC expose the survey process, and we’ve also given input that we improve it [and] make it more accurate. Adding transparency to the process might be a way to improve it.”
In its review, the GAO – a nonpartisan investigational agency of Congress – cited several weaknesses in the data collected by the RUC, including that some RUC survey data had low response rates, a low total number of responses, and large ranges in responses.
For example, the GAO found that the median number of responses to surveys for payment year 2015 was 52 but the median response rate was only 2%, and that 23 of the 231 surveys had under 30 respondents.
The report also questions the transparency of the CMS process for establishing relative values. Although the CMS states that it complies with statutory requirements to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews, according to the GAO report.
The CMS also does not publish the potentially misvalued services identified by the RUC, so stakeholders are unaware that these services will be reviewed and payment rates for these services may change.
The report found that the CMS provides some information about its process in its rule-making but does not document the methods used to review specific RUC recommendations. For example, the CMS does not document which resources were considered during its review of RUC recommendations for specific services. The GAO report said the CMS relies too heavily on RUC recommendations when establishing relative values.
“GAO found that, in the majority of cases, CMS accepts the RUC’s recommendations, and participation by other stakeholders is limited,” the report authors said. “Given the process- and data-related weaknesses associated with the RUC’s recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.”
The AMA argued that the GAO report should have better acknowledged the difficulty in obtaining data on services that are infrequently performed. For example, 80% of services paid with work valuation on the Medicare physician payment schedule have fewer than 10,000 Medicare claims per year, the association noted.
“A service performed 10,000 times per year, is done, on average, less than once per day in any state,” the AMA spokesperson said. “It would be nearly impossible to do accurate direct observation or time/motion studies to collect time data on these low volume services. The survey methodology, followed by rigorous cross-specialty RUC review, is the best way to accomplish this data collection.”
The current GAO report is far from the first to criticize the RUC. The AAFP has long argued that the RUC should include more family physicians, health plans, consumers, employers, and health care economists on its panel. In 2012, the committee added another seat for geriatric medicine and another rotating primary care seat.
In an interview, Dr. Wergin said these additions helped, but that the AAFP would like to see at least one more primary care slot, as well as slots for other stakeholders. In a January 2014 letter, the AAFP called on the CMS to correct what the AAFP referred to as “a disturbing trend seen in the recommendations of RUC.” Specifically, the AAFP urged the CMS to address undervalued services, such as office-based evaluation and management (E/M) codes.
The Medicare Payment Advisory Commission (MedPAC), an independent advisory commission to Congress, has also issued several reports questioning the effectiveness of the RUC, including a 2011 white paper that expressed skepticism about the way in which data is collected by the panel. In 2013, MedPAC executive director Mark E. Miller, in testimony before the Senate Finance Committee, criticized how the RUC operated.
In the last Congress, Rep. Jim McDermott (D-Wash.), ranking member of the Ways and Means Committee’s Subcommittee on Health, introduced the Accuracy in Medicare Physician Payment Act of 2013, which would supplement the work of RUC by establishing an expert panel within Medicare to oversee the valuation of physician services and to help correct distortions in the physician fee schedule. The bill was not considered by the House.
On Twitter @legal_med
A government watchdog report suggests that the Centers for Medicare & Medicaid Services may be setting Medicare payment rates inaccurately based on biased recommendations from its panel of physician experts.
The Government Accountability Office (GAO) questions the transparency of the CMS’ rate calculation process and suggests that members of the American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) have conflicts of interest that affect their ability to fairly value physician services, according to a report published May 21.
The GAO report recommends that the CMS better document its process for establishing relative values and develop a process to inform the public of potentially misvalued services identified by the RUC. The CMS also should develop a plan for using funds appropriated for the collection and use of information on physicians’ services in the determination of relative values, the report stated.
In response, the American Medical Association defended the expertise and objectivity of the RUC, stressing that there is no substitute for input from experienced physicians regarding the time and resources that go into medical services.
“The RUC’s valuable expertise is balanced with the oversight of government officials who have the final say,” an AMA spokesperson said in an interview. “When CMS’ initial efforts to identify potentially misvalued services were unable to obtain reliable data from government contractors, physicians on the RUC took on this important task. When gauging how much time and resources go into one medical service compared with another, no one knows more about what is involved in providing services to Medicare patients than the physicians who care for them.”
Dr. Robert L. Wergin, president of the American Academy of Family Physicians (AAFP) said the GAO report findings are consistent with previous concerns raised by the AAFP about the RUC.
“We have advocated for more transparency” in the past, Dr. Wergin said in an interview. “We have requested that the RUC expose the survey process, and we’ve also given input that we improve it [and] make it more accurate. Adding transparency to the process might be a way to improve it.”
In its review, the GAO – a nonpartisan investigational agency of Congress – cited several weaknesses in the data collected by the RUC, including that some RUC survey data had low response rates, a low total number of responses, and large ranges in responses.
For example, the GAO found that the median number of responses to surveys for payment year 2015 was 52 but the median response rate was only 2%, and that 23 of the 231 surveys had under 30 respondents.
The report also questions the transparency of the CMS process for establishing relative values. Although the CMS states that it complies with statutory requirements to review all Medicare services every 5 years, the agency does not maintain a database to track when a service was last valued or have a documented standardized process for prioritizing its reviews, according to the GAO report.
The CMS also does not publish the potentially misvalued services identified by the RUC, so stakeholders are unaware that these services will be reviewed and payment rates for these services may change.
The report found that the CMS provides some information about its process in its rule-making but does not document the methods used to review specific RUC recommendations. For example, the CMS does not document which resources were considered during its review of RUC recommendations for specific services. The GAO report said the CMS relies too heavily on RUC recommendations when establishing relative values.
“GAO found that, in the majority of cases, CMS accepts the RUC’s recommendations, and participation by other stakeholders is limited,” the report authors said. “Given the process- and data-related weaknesses associated with the RUC’s recommendations, such heavy reliance on the RUC could result in inaccurate Medicare payment rates.”
The AMA argued that the GAO report should have better acknowledged the difficulty in obtaining data on services that are infrequently performed. For example, 80% of services paid with work valuation on the Medicare physician payment schedule have fewer than 10,000 Medicare claims per year, the association noted.
“A service performed 10,000 times per year, is done, on average, less than once per day in any state,” the AMA spokesperson said. “It would be nearly impossible to do accurate direct observation or time/motion studies to collect time data on these low volume services. The survey methodology, followed by rigorous cross-specialty RUC review, is the best way to accomplish this data collection.”
The current GAO report is far from the first to criticize the RUC. The AAFP has long argued that the RUC should include more family physicians, health plans, consumers, employers, and health care economists on its panel. In 2012, the committee added another seat for geriatric medicine and another rotating primary care seat.
In an interview, Dr. Wergin said these additions helped, but that the AAFP would like to see at least one more primary care slot, as well as slots for other stakeholders. In a January 2014 letter, the AAFP called on the CMS to correct what the AAFP referred to as “a disturbing trend seen in the recommendations of RUC.” Specifically, the AAFP urged the CMS to address undervalued services, such as office-based evaluation and management (E/M) codes.
The Medicare Payment Advisory Commission (MedPAC), an independent advisory commission to Congress, has also issued several reports questioning the effectiveness of the RUC, including a 2011 white paper that expressed skepticism about the way in which data is collected by the panel. In 2013, MedPAC executive director Mark E. Miller, in testimony before the Senate Finance Committee, criticized how the RUC operated.
In the last Congress, Rep. Jim McDermott (D-Wash.), ranking member of the Ways and Means Committee’s Subcommittee on Health, introduced the Accuracy in Medicare Physician Payment Act of 2013, which would supplement the work of RUC by establishing an expert panel within Medicare to oversee the valuation of physician services and to help correct distortions in the physician fee schedule. The bill was not considered by the House.
On Twitter @legal_med
Report IDs insurance barriers to breastfeeding services
Dr. Holly S. Puritz, an ob.gyn. in Norfolk, Va., wasn’t surprised by the findings of a recent report that claims insurers are failing to cover breastfeeding services as required by the Affordable Care Act.
“If I’m being charitable, I would say lots of the new rules are confusing and difficult for anyone to sort out,” said Dr. Puritz, who is in private practice and is also medical director for labor and delivery at Sentara Leigh Hospital. “However, my gut tells me that anything a company can put off paying for any amount of time equals profit, and most insurance companies have shareholders they answer to.”
The National Women’s Law Center (NWLC) found that at least 20 insurance companies are disregarding some ACA requirements by limiting coverage of breast pump purchases or failing to provide in-network lactation counselors.
For its report, published on May 21, NWLC analyzed coverage of breastfeeding support and supplies offered in the health insurance marketplaces of 15 states during 2014 and 2015. Researchers also reviewed personal accounts from patients collected from emails and calls to the center’s hotline.
The NWLC found that some health plans are placing improper coverage limits on breastfeeding benefits, including only allowing women to receive lactation services within 2 months of delivery; failing to cover breast pumps until after a baby is born; and denying claims for out-of-network lactation consultants even when in-network services are not available.
The ACA requires that insurers cover breastfeeding supplies and counseling without copays, deductibles, or coinsurance.
“The Affordable Care Act has made dramatic improvements in women’s health coverage,” Gretchen Borchelt, vice president for health and reproductive rights at NWLC, said in a statement. “If insurance companies fail to comply, they are illegally blocking further progress toward helping women breastfeed successfully. Everyone involved, from insurance companies to federal regulators, must work together to ensure that breastfeeding coverage fulfills the promise of the ACA.”
But America’s Health Insurance Plans (AHIP), a trade group representing the insurance industry, criticized the report, calling the study unscientific and lacking hard data.
“This report presents a distorted picture of reality,” AHIP President and CEO Karen Ignagni said in an interview. “Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys. To use highly selective anecdotes to draw sweeping conclusions about consumers’ coverage does nothing to improve the quality, accessibility, or affordability of health care for individuals and families.”
During its study, NWLC researchers found that physicians were generally very supportive in getting their patients’ help from trained lactation providers when possible, said Anna C. Benyo, NWLC senior health policy analyst. In some cases, pediatricians’ offices had a registered nurse who was also a trained lactation consultant and who could provide some education and support during well-child visits, Ms. Benyo said in an interview.
“But, for the most part, the pediatrician wants women to get help, and then [patients] try to find a provider who takes their insurance, and that’s where things start to fall apart,” Ms. Benyo said. “Their insurance company hasn’t set up a network and when they try to go out-of-network as allowed by federal rules, the plans deny coverage.”
In cases where the type of pump is an issue, Ms. Benyo said physicians sometimes write prescriptions for hospital-grade pumps to help patients get the needed equipment. Under the ACA, insurance plans are not required to cover a certain type of pump, leading some plans to cover only manual pumps and exclude electronic or hospital-grade pumps.
Dr. Puritz said she and her colleagues have written prescriptions for hospital-grade pumps.
“The hospital-grade breast pumps that are now covered [by prescription] are a huge improvement for women who want to breastfeed [versus] the less expensive ones that many women would try as that was what they could afford,” she said in an interview. “They didn’t work well and discouraged many of my patients from continuing to nurse.”
For physicians, seeing patients struggle to obtain insurance coverage for needed medical supplies is frustrating, Dr. Puritz added. She said she has not seen any specific cases involving coverage denials for breastfeeding services, but in general, the problem is troublesome.
“Coverage improves access plain and simple,” Dr. Purtiz said. “The problem is when physicians get denials, it’s lots of extra work for them and their staff. They have to be really committed to make it work.”
On Twitter @legal_med
Dr. Holly S. Puritz, an ob.gyn. in Norfolk, Va., wasn’t surprised by the findings of a recent report that claims insurers are failing to cover breastfeeding services as required by the Affordable Care Act.
“If I’m being charitable, I would say lots of the new rules are confusing and difficult for anyone to sort out,” said Dr. Puritz, who is in private practice and is also medical director for labor and delivery at Sentara Leigh Hospital. “However, my gut tells me that anything a company can put off paying for any amount of time equals profit, and most insurance companies have shareholders they answer to.”
The National Women’s Law Center (NWLC) found that at least 20 insurance companies are disregarding some ACA requirements by limiting coverage of breast pump purchases or failing to provide in-network lactation counselors.
For its report, published on May 21, NWLC analyzed coverage of breastfeeding support and supplies offered in the health insurance marketplaces of 15 states during 2014 and 2015. Researchers also reviewed personal accounts from patients collected from emails and calls to the center’s hotline.
The NWLC found that some health plans are placing improper coverage limits on breastfeeding benefits, including only allowing women to receive lactation services within 2 months of delivery; failing to cover breast pumps until after a baby is born; and denying claims for out-of-network lactation consultants even when in-network services are not available.
The ACA requires that insurers cover breastfeeding supplies and counseling without copays, deductibles, or coinsurance.
“The Affordable Care Act has made dramatic improvements in women’s health coverage,” Gretchen Borchelt, vice president for health and reproductive rights at NWLC, said in a statement. “If insurance companies fail to comply, they are illegally blocking further progress toward helping women breastfeed successfully. Everyone involved, from insurance companies to federal regulators, must work together to ensure that breastfeeding coverage fulfills the promise of the ACA.”
But America’s Health Insurance Plans (AHIP), a trade group representing the insurance industry, criticized the report, calling the study unscientific and lacking hard data.
“This report presents a distorted picture of reality,” AHIP President and CEO Karen Ignagni said in an interview. “Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys. To use highly selective anecdotes to draw sweeping conclusions about consumers’ coverage does nothing to improve the quality, accessibility, or affordability of health care for individuals and families.”
During its study, NWLC researchers found that physicians were generally very supportive in getting their patients’ help from trained lactation providers when possible, said Anna C. Benyo, NWLC senior health policy analyst. In some cases, pediatricians’ offices had a registered nurse who was also a trained lactation consultant and who could provide some education and support during well-child visits, Ms. Benyo said in an interview.
“But, for the most part, the pediatrician wants women to get help, and then [patients] try to find a provider who takes their insurance, and that’s where things start to fall apart,” Ms. Benyo said. “Their insurance company hasn’t set up a network and when they try to go out-of-network as allowed by federal rules, the plans deny coverage.”
In cases where the type of pump is an issue, Ms. Benyo said physicians sometimes write prescriptions for hospital-grade pumps to help patients get the needed equipment. Under the ACA, insurance plans are not required to cover a certain type of pump, leading some plans to cover only manual pumps and exclude electronic or hospital-grade pumps.
Dr. Puritz said she and her colleagues have written prescriptions for hospital-grade pumps.
“The hospital-grade breast pumps that are now covered [by prescription] are a huge improvement for women who want to breastfeed [versus] the less expensive ones that many women would try as that was what they could afford,” she said in an interview. “They didn’t work well and discouraged many of my patients from continuing to nurse.”
For physicians, seeing patients struggle to obtain insurance coverage for needed medical supplies is frustrating, Dr. Puritz added. She said she has not seen any specific cases involving coverage denials for breastfeeding services, but in general, the problem is troublesome.
“Coverage improves access plain and simple,” Dr. Purtiz said. “The problem is when physicians get denials, it’s lots of extra work for them and their staff. They have to be really committed to make it work.”
On Twitter @legal_med
Dr. Holly S. Puritz, an ob.gyn. in Norfolk, Va., wasn’t surprised by the findings of a recent report that claims insurers are failing to cover breastfeeding services as required by the Affordable Care Act.
“If I’m being charitable, I would say lots of the new rules are confusing and difficult for anyone to sort out,” said Dr. Puritz, who is in private practice and is also medical director for labor and delivery at Sentara Leigh Hospital. “However, my gut tells me that anything a company can put off paying for any amount of time equals profit, and most insurance companies have shareholders they answer to.”
The National Women’s Law Center (NWLC) found that at least 20 insurance companies are disregarding some ACA requirements by limiting coverage of breast pump purchases or failing to provide in-network lactation counselors.
For its report, published on May 21, NWLC analyzed coverage of breastfeeding support and supplies offered in the health insurance marketplaces of 15 states during 2014 and 2015. Researchers also reviewed personal accounts from patients collected from emails and calls to the center’s hotline.
The NWLC found that some health plans are placing improper coverage limits on breastfeeding benefits, including only allowing women to receive lactation services within 2 months of delivery; failing to cover breast pumps until after a baby is born; and denying claims for out-of-network lactation consultants even when in-network services are not available.
The ACA requires that insurers cover breastfeeding supplies and counseling without copays, deductibles, or coinsurance.
“The Affordable Care Act has made dramatic improvements in women’s health coverage,” Gretchen Borchelt, vice president for health and reproductive rights at NWLC, said in a statement. “If insurance companies fail to comply, they are illegally blocking further progress toward helping women breastfeed successfully. Everyone involved, from insurance companies to federal regulators, must work together to ensure that breastfeeding coverage fulfills the promise of the ACA.”
But America’s Health Insurance Plans (AHIP), a trade group representing the insurance industry, criticized the report, calling the study unscientific and lacking hard data.
“This report presents a distorted picture of reality,” AHIP President and CEO Karen Ignagni said in an interview. “Health plans provide access to care for millions of women each day and receive high marks in customer satisfaction surveys. To use highly selective anecdotes to draw sweeping conclusions about consumers’ coverage does nothing to improve the quality, accessibility, or affordability of health care for individuals and families.”
During its study, NWLC researchers found that physicians were generally very supportive in getting their patients’ help from trained lactation providers when possible, said Anna C. Benyo, NWLC senior health policy analyst. In some cases, pediatricians’ offices had a registered nurse who was also a trained lactation consultant and who could provide some education and support during well-child visits, Ms. Benyo said in an interview.
“But, for the most part, the pediatrician wants women to get help, and then [patients] try to find a provider who takes their insurance, and that’s where things start to fall apart,” Ms. Benyo said. “Their insurance company hasn’t set up a network and when they try to go out-of-network as allowed by federal rules, the plans deny coverage.”
In cases where the type of pump is an issue, Ms. Benyo said physicians sometimes write prescriptions for hospital-grade pumps to help patients get the needed equipment. Under the ACA, insurance plans are not required to cover a certain type of pump, leading some plans to cover only manual pumps and exclude electronic or hospital-grade pumps.
Dr. Puritz said she and her colleagues have written prescriptions for hospital-grade pumps.
“The hospital-grade breast pumps that are now covered [by prescription] are a huge improvement for women who want to breastfeed [versus] the less expensive ones that many women would try as that was what they could afford,” she said in an interview. “They didn’t work well and discouraged many of my patients from continuing to nurse.”
For physicians, seeing patients struggle to obtain insurance coverage for needed medical supplies is frustrating, Dr. Puritz added. She said she has not seen any specific cases involving coverage denials for breastfeeding services, but in general, the problem is troublesome.
“Coverage improves access plain and simple,” Dr. Purtiz said. “The problem is when physicians get denials, it’s lots of extra work for them and their staff. They have to be really committed to make it work.”
On Twitter @legal_med
Eight states enact telemedicine law, commission to be created
Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).
Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.
“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.
The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.
Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.
Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).
Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.
“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.
The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.
Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.
Minnesota and Alabama have joined six other states in enacting a law that aims to expand the practice of telemedicine by streamlining physician licensure. Alabama Gov. Robert Bentley (R) and Minnesota Gov. Mark Dayton (D) on May 19 each signed into law the Interstate Medical Licensure Compact, model legislation developed by the Federation of State Medical Boards (FSMB).
Larry D. Dixon, executive director for the Alabama Board of Medical Examiners, said the law will help ease the physician shortage in rural and other underserved areas.
“Now that [eight] states have enacted the compact legislation, we can begin the real work of establishing the compact to ensure patients have access to quality health care services, while maintaining the highest level of patient protections,” Mr. Dixon said in a statement.
The FSMB also announced the creation of a commission that will meet later this year to discuss the management and administration of the compact. Members of the commission will include two voting representatives appointed by each member state. Commissioners will be selected from physicians appointed to a member board, executives of a member board, or members of the public appointed to a member board.
Under the compact legislation approved physicians would be under the jurisdiction of the state medical board in which the patient is located at the time of the medical interaction. State boards of medicine would retain their individual authority for discipline and oversight. Interested physicians would also need to complete a background check including biometric data (such as fingerprints) and pass all components of either the U.S. Medical Licensing Examination or the Comprehensive Osteopathic Medicine Licensing Examination within three attempts.
The model legislation has been introduced in nearly 20 state legislatures. Alabama and Minnesota join Idaho, Montana, South Dakota, Utah, West Virginia, and Wyoming in enacting the law.
UnitedHealth Group agrees to $11.5 million settlement
After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.
UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.
Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.
“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.
Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.
“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.
The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”
The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.
Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.
In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.
The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.
“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.
On Twitter @legal_med
After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.
UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.
Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.
“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.
Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.
“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.
The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”
The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.
Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.
In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.
The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.
“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.
On Twitter @legal_med
After nearly 15 years of litigation between UnitedHealth Group Inc. and a group of physicians, the health insurance giant agreed to pay $11.5 million to resolve allegations that it incorrectly paid and managed doctors’ billing claims.
UnitedHealth Group and its subsidiaries agreed to spend at least $9 million in enhancements to its provider self-service website to increase efficiency and reduce delays in managing of claims. The additional funds will go toward educational programs for medical society members pertaining to ICD-10-CM coding, CPT coding, medical review audits, appeals, and claims submission and processing. The settlement stems from lawsuits filed in 2001 by the Medical Society of the State of New York, the Connecticut State Medical Society, the North Carolina Medical Society, the Tennessee Medical Association, and several individual physicians.
Daryl Richard, UnitedHealth Group spokesman, said that the insurer was pleased to finally be ending the litigation, and that the company looks forward to new ways of collaborating with doctors.
“Physicians will have simpler and more comprehensive access to claims management information through enhancements we are making to our physician website,” Mr. Richard said in a statement.
Dr. Joseph Maldonado, president of the New York medical society, said the settlement was a significant victory for physicians.
“This settlement will improve access to information and the ability to adjust claims for all in-network physicians contracting with United and submitting claims, while providing certain benefits to member physicians,” he said in a statement.
The case was part of a series of lawsuits filed in the early 2000s alleging illegal business practices and corruption by Aetna, Cigna, UnitedHealthcare, Healthnet, Humana, PacifiCare, Prudential, and WellPoint. The suits alleged that the defendants engaged in a conspiracy to wrongfully and fraudulently pay doctors less than the amounts to which they were entitled. Several of the cases were consolidated into what is referred to in court documents as “the lead case.”
The medical societies’ litigation was halted pending the outcome of the lead case, according to the UnitedHealth Group settlement documents. Following a 2007 ruling for defendants in the lead case, plaintiffs in the medical societies’ case attempted to revive their litigation, and a lengthy court battle ensued. The parties tried unsuccessfully to negotiate a settlement for years.
Meanwhile, settlements were eventually reached in the lead case with insurers agreeing to change their business practices and reimburse the plaintiff physicians for hundreds of million dollars, according to a summary by the American Medical Association, a plaintiff in one of the original cases. In addition, the settlements required the insurers to disclose their coding edits, adopt certain CPT conventions, and clarify the criteria under which medical procedures will be deemed medically necessary.
In its settlement with the medical societies, UnitedHealth Group denied all allegations in the suit and admitted no wrongdoing. For their part, the medical societies stated the claims have merit, but that they will dismiss the suit following payment of the settlement, according to court documents.
The settlement will offer significant relief in the areas of claims management and claims resolution, said Edith Kallas, a New York–based attorney and legal counsel for plaintiffs.
“We applaud the medical societies and individual physicians for their commitment to obtaining a meaningful resolution of these issues,” she said in a statement.
On Twitter @legal_med
VIDEO: Patient-generated health tests pose challenges, opportunities for doctors
CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?
Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.
In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?
Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.
In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
CHICAGO – Technology advances are giving patients direct access to myriad health tests and their own health data, but what role do physicians have in responding to such patient-generated assessments?
Dr. Marc Triola of New York University in New York says that the growing reach of health care technology presents both challenges and opportunities for the physician-patient relationship. Dr. Triola spoke at the annual meeting of the American Medical Women’s Association about how physicians can embrace technology and use advancements to improve quality of care.
In this video interview, Dr. Triola speaks about the new ways in which patients can assess their own health data and how doctors should address the test results. He also discusses barriers posed by new technology and how physicians can help shape the changing delivery of health care.
The video associated with this article is no longer available on this site. Please view all of our videos on the MDedge YouTube channel
On Twitter @legal_med
AT THE AMWA ANNUAL MEETING
