Managed Care - January 2009 - (Page 6)

LEGISLATION & REGULATION Silent PPOs Spur Doctor Push-Back Lobbying state legislatures pays off for physician groups, and now health plans must provide more detail on who leases their networks By John Carroll F or almost a decade, the American Medical Association has set its sights on eliminating what it sees as a thorn in the sides of doctors around the country — one state at a time. Time and again, the AMA says, physicians bill for their work only to discover that the patient is covered by a payer operating off their practice’s radar at a discounted rate they had negotiated with another carrier. The AMA years ago dubbed them silent PPOs. They lease provider networks from health plans, claiming the same discounts and leaving doctors and their staffs scrambling to clarify billing arrangements. Tough to track down “It’s something we’ve been hearing about for years now,” says AMA Trustee Jeremy Lazarus, MD. “It’s very difficult to find out about the silent PPOs. Given the amount of time it takes for [staff members] to find out about them, doctors often just throw up their hands and say forget about it. To track these down is just mind-boggling.” So the doctors turned to state legislatures to put an end to the practice. They’ve been making steady gains. Over the past two years, state medical groups in Ohio, Colorado, Connecticut, Indiana, and Florida have all won passage of legislation hammering out new terms to govern these so-called silent PPOs. Now a national group of state insurance legislators has wrapped up more than two years of talks with a compromise bill that physicians from coast to coast are expected to pick up and take to their lawmakers in the next session. The new bill spells out in detail how insurers have to offer doctors a simple method to determine who leased their networks. Members of mystery payers who can’t easily prove their status will be billed at out-of-network rates. But Silent PPOS irritate doctors because who’s paying and why that payer expects a certain rate isn’t clear, says Tim Maglione at the Ohio State Medical Association. there are some issues yet to be resolved, chief among them being an unresolved push by the physicians to make sure that all payers operating under federal ERISA (Employee Retirement Income Security Act) rules have to comply with state law. Lazarus says health plans should also expect to hear more about the leasing issue as they sit down with physician groups for their next round of contract talks. “About two years ago we set out to try and allow interested parties to work together and develop a model bill, but folks had their own issues. It didn’t play forward,” says Susan Nolan, executive director of the National Conference of Insurance Legislators (NCOIL). One roadblock is downstream rentals. Providers said they never had any easy way to determine how many companies had access to the rates they had negotiated, says Nolan. Another sticking point is that self-insured plans operating under ERISA wanted to keep the exemption from state law laid out by the federal statute. The AMA felt that any compromise bill should cover all insurers, regardless of ERISA status. Doctors complain that “they’ll have a payment show up from a payer they’ve never heard of before,” says Tim Maglione, senior director for government relations at the Ohio State Medical Association, which helped write one of the most aggressive new state laws. “I don’t have a contract; how are they paying? And then you trace back and find it was a rental arrangement. The reason they’re called silent PPOs is that you just didn’t know where this payment came from and why.” Access allowed In Ohio, Anthem Blue Cross & Blue Shield is the largest insurer, says Maglione. “United Healthcare has a big presence and Humana has a presence, as well as Cigna. 6 MANAGED CARE / JANUARY 2009

Table of Contents Feed for the Digital Edition of Managed Care - January 2009

Managed Care - January 2009 Editor's Memo Contents Legislation & Regulation News and Commentary Medication Management Compensation Monitor Health Care's Disruptive Innovations Q&A With Clayton Christensen 'Disruption' May Be Plans' Best Bet Avoid the PBM Rebate Trap HealthPartners Puts Diabetes on Notice Formulary Files Plan Watch Tomorrow's Medicine Ad Index Outlook Unmet Needs in the Management of Plaque Psoriasis Impact of RSV: Implications for Managed Care

Managed Care - January 2009

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