APMA News - October 2011 - (Page 28)

Can They Really Do That? By Laura Pickard, DPM FAQs about Private Insurance Contracting, Part III QUESTION: Can insurance plans outsource services to a specialty network and thereby exclude me from providing covered procedures allowed by my scope of practice? ANSWER: Health plans increasingly are outsourcing utilization review for specific services to organizations that specialize in those services. In some cases, in addition to utilization review, the organization offers a network of providers to furnish the services. The health plan may decide to furnish the designated services exclusively through the specialty network. For example, in Illinois, CIGNA contracted with OrthoNet to provide physical therapy services. CIGNA began denying payment for physical therapy services furnished by podiatrists because OrthoNet was responsible for providing such services. When I called OrthoNet to inquire about participation in its physical therapy network, I was told that OrthoNet does not contract with podiatrists to furnish physical therapy services. Other podiatrists have complained of similar issues with regard to outsourcing of durable medical equipment. In evaluating whether a health plan can implement such a policy, a physician should first look to his or her contract. Does the contract obligate the health plan to compensate you for all “covered services” that are within the scope of your licensure? Is there any term in the contract that allows the health plan to outsource specific services or otherwise limit the scope of services covered under the contract? If there is a broad obligation to reimburse you for all covered services you provide and no language allowing the plan to limit the scope of services, you have an argument that the plan’s failure to reimburse you for providing covered services within the scope of your license is a breach of the contract. State law may also provide an argument against a health plan’s ability to implement such a policy in instances in which, as in Illinois, the policy has the effect of excluding podiatrists from obtaining reimbursement for furnishing the service at issue. For example, many states have laws that require health plans to reimburse podiatrists and/or other providers for services within the scope of their licensure if the health plan covers such services. For example, Kentucky law states: “Any certificate, agreement, or contract issued in this state by a health maintenance organization which provides coverage for any service which is within the lawful scope of practice of a podiatrist duly licensed under KRS Chapter 311, shall be deemed to provide benefits for those services whether performed by a duly licensed physician, osteopath, chiropractor, or podiatrist, notwithstanding any pro28 APMA News October 2011 vision contained in the certificate, agreement, or contract.” (KY Rev. Stat. Ann. 304.38-196) South Carolina law states: “A point of service option or closed panel health plan offered pursuant to this article may not discriminate against a physician, a podiatrist, an optometrist, an oral surgeon, or a chiropractor by excluding the provider from participating in the plan on the basis of the profession. A health care plan may not exclude these providers from providing health care services which they are licensed to provide and which are covered by the plan and as determined by medical necessity under utilization review guidelines.” (SC Code Ann. 38-71-1730) While state laws typically give a health plan the freedom to choose the providers in its network (i.e., there are not anywilling-provider mandates), a health plan that organized its provider network in a manner to exclude podiatrists from providing specific services in the scope of their licensure would arguably violate such laws. When considering possible state law remedies, it is important to keep in mind the limited application of state law to health plans. State law generally does not apply to self-insured ERISA plans, to Federal Employee Health Benefit plans, or Medicare Advantage plans. In addition, the state law may only apply to a subset of state-regulated plans (for example, to indemnity plans or the out-of-network benefits of a PPO) but not managed care organizations. Another potential way to address outsourcing arrangements that exclude podiatrists from furnishing covered services within the scope of their licensure is to address the issue directly with the health plan. Podiatrists should note any patient hardships caused by outsourcing. For example, outsourcing could cause patients undue burden or hardship in obtaining the services, or it could potentially lower the quality of care that members of the plan receive. If podiatrists observe such hardships, they should contact, directly or through their state association, the health plan’s medical director or provider resources staff to discuss the impact of the outsourcing program. While it is unlikely that a health plan would be in a position to entirely dismantle the program, it may choose to address aspects of the program that particularly affect its members or quality of care. n Dr. Pickard can be reached at ljpickard@apma.org.

Table of Contents for the Digital Edition of APMA News - October 2011

APMA News - October 2011
President’s Message
Contents
ICD-10 in Practice: Coding for Fifth Metatarsal Injury
ICD-10 Benchmarks and Timeline
Team APMA Runs Away with the Show
Medical Mission to Costa Rica: Identifying Fungal Infections of the Foot
Federal Advocacy Forum
Resolutions Submissions
IT Consultant
Can They Really Do That?
Reimbursement
Members Who Know Media
Technofile
Young Voices
Small Business 101
APMAPAC Chair Report
APMA All Stars
In Short
Worthy of Note
Affiliates Corner
List of Affiliated Organizations
Insurance Advisor
New Members
Death Notices
Annual Scientific Meeting Registration Form
Annual Scientific Meeting Sponsors
APMAPAC Update
Development Update
Classified Advertising
Dates to Remember
Advertising Index
10 Questions

APMA News - October 2011