Updated payor profiles for 2017 now available The California Medical Association’s (CMA) Center for Economic Services is publishing updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, and other key contacts. Don’t waste your time searching the internet for this information – members can download CMA’s Payor Profiles free of charge in the CMA Resource Library. August 1, 2017 CMA, Managed Care, Medi-Cal, Medicare Aetna, Anthem Blue Cross, Blue Shield, Cigna, Health Net, Insurance, Medi-Cal, Medicare, Noridian, Payor, Payor Profiles, Running a Practice, UnitedHealthcare 0 0 Comment Read More »
Large insurers drop barriers to prescribing medications for opioid use disorder Three of the nation's largest insurers—Aetna, Cigna, and Anthem Blue Cross—have in recent months announced that they will no longer require physicians to seek prior approval before prescribing medication to treat opioid use disorder. These policy changes come as more than 2.2 million people meet the diagnostic criteria for an opioid use disorder. Treatment of opioid use disorder with opioid maintenance therapies has been shown to be cost-effective, safe and successful when used appropriately. Increasing access to treatment is crucial to addressing opioid misuse and overdose, and the California Medical Association urges all insurers to make patient care a priority over administrative hurdles. Prior authorization often has a negative impact on patient care when there is a delay or interruption in ongoing treatment due to a health plan utilization authorization. According to the American Medical Association, 75 percent of surveyed physicians described prior authorization burdens as high or extremely high. More than a third of physicians reported having staff that work exclusively on prior authorization. Nearly 60 percent of physicians reported that their practices wait, on average, at least one business day for prior authorization decisions, and more than 25 percent of physicians said they wait three business days or longer. Contact: Samantha Pellon, (916) 551-2887 or spellon@cmanet.org. March 2, 2017 General Aetna, Anthem Blue Cross, Cigna, Opioids, Preauthorization 0 0 Comment Read More »
CMA applauds U.S. Justice Department lawsuit against health insurance mega-mergers The California Medical Association (CMA) today applauded the U.S. Department of Justice (DOJ) for filing two lawsuits challenging the proposed merger of Anthem and Cigna and of Aetna and Humana — all of which are among the largest health insurance companies in the country. “We applaud the DOJ for protecting patients against mega-mergers that would drastically reduce competition in the health insurance market, leaving patients at a huge disadvantage in the pursuit of timely and affordable health care,” said CMA President Steven Larson, M.D., MPH. “We also commend California Insurance Commissioner Dave Jones for his leadership in scrutinizing these proposed mergers and for protecting California patients, physicians and our health care system.” An overwhelming 85 percent of California physicians opposed the Anthem-Cigna merger, while 83 percent opposed the Aetna-Humana merger, according to a recent CMA survey. Physicians had concerns that the health insurer unions could lead to narrower physician networks, forcing physicians to provide fewer services. “California physicians understand that giving complete market power to just a few for-profit insurers is not in the best interest of patients,” said CMA General Counsel Francisco J. Silva. “CMA’s opposition to the Anthem-Cigna merger confirmed the obvious: if approved, the merger would further empower Anthem to contract with fewer physicians, limit choice for patients, increase wait times for referrals and increase premiums. Competition is necessary to ensure high-quality care, which is why we continue to denounce these mergers.” CMA has expressed concerns with the mergers for months, urging action, testifying before regulators and publishing news articles and statements condemning the consolidation. To view the results of the CMA survey, click here. Contact: Griffin Rogers, (916) 551-2870 or grogers@cmanet.org. August 5, 2016 Managed Care Aetna, Anthem Blue Cross, Cigna, Department of Justice, DOJ, Advocacy, Humana 0 0 Comment Read More »
DOJ files lawsuit to block two health insurance mega-mergers The U.S. Department of Justice (DOJ) today filed two lawsuits to block health insurance mega-mergers that would compromise patients’ access to care, and negatively impact the quality and affordability of health care across the country. “If allowed to proceed, these mergers would fundamentally reshape the health insurance industry,” U.S. Attorney General Loretta Lynch said at a press conference. “They would leave much of the multi-trillion dollar health insurance industry in the hands of three mammoth insurance companies, restricting competition in key markets.” The California Medical Association (CMA) has long-held concerns over reduced competition and increased health plan market power. “Without competition, the health insurance companies will run unchecked. For the sake of those who desperately need medical care, we must not let this happen," said CMA President Steven E. Larson, M.D., MPH. For the past six months, there had been speculation over whether federal antitrust officials would intervene to stop a $54 billion merger between Anthem and Cigna and a $37 billion deal between Aetna and Humana. The companies argued the mergers would benefit consumers and shareholders, but many legislators, state regulators and medical associations, including CMA and the American Medical Association, remained concerned that the deals would reduce competition and drive up costs for patients. Earlier this year, CMA conducted a survey to determine California physicians’ perspective on the Anthem-Cigna and Aetna-Humana mergers. The results showed that 85 percent of California’s physicians opposed the mergers. The CMA survey – which gathered data from 989 practices in 47 California counties, representing physicians from a range of specialties and practice sizes – sought not only to gauge California physicians’ temperature on the proposed mergers, but also to gather insight into the tactics undertaken by insurance companies in their negotiations with physicians. The vast majority of surveyed physicians were concerned that market consolidation would narrow physician networks, making it more difficult for patients to find care from in-network physicians; reduce physicians’ ability to advocate on behalf of their patients; and reduce the quantity or quality of services that physicians can offer their patients. (To see full CMA survey results, click here.) Physicians strongly believe that health insurer consolidation compromises the ability of physicians to advocate for their patients. Physicians’ experience with past mergers demonstrates that increased market power allows insurers to exert control over clinical decisions, which has undermined the patient-physician relationship and eliminates crucial patient care safeguards. Competition among health insurers, on the other hand, can lower premiums, enhance customer service and spur innovative ways to improve quality while lowering costs. August 5, 2016 Managed Care Cigna, Department of Justice, DOJ, Aetna, Anthem Ble Cross, Humana 0 0 Comment Read More »
CMA seeking physician feedback on proposed health insurance mergers Proposed mergers of the some of the largest national health insurance companies have been announced, with Aetna reaching a $37 billion deal to purchase Humana, and Anthem agreeing to purchase Cigna for $48.4 billion. State and federal regulators are interested in knowing the prospective effects of these possible mergers on your practice and patient care. The California Medical Association (CMA), in collaboration with the American Medical Association, is asking for your feedback on these proposed mergers. The survey should take about 8-9 minutes to complete. Only de-identified data will be used in our reporting. It is important that we receive your feedback no later than Friday, February 12, 2016. To complete the survey, click here. February 9, 2016 Managed Care Anthem Blue Cross, Cigna, Humana, Aetna 0 0 Comment Read More »
Aetna issues physician terminations over frequency of E/M visits The California Medical Association (CMA) has received several reports from physicians in the San Francisco Bay Area that they’ve received contract termination notices from Aetna due to their above-average use of high-level Evaluation and Management (E/M) codes. The termination letters, issued by Aetna in mid-January, advised physicians that upon review of claims for a one year period, their usage of high level E/M codes was “significantly outside the norm” of comparative physicians within their market. CMA has learned that approximately 40 physicians within the Northern California Aetna PPO network were issued the notice of termination. Contrary to the one-year timeframe for review stipulated in the termination notice, Aetna has advised that the review actually included approximately 30 months of prior claims data. Physicians whose billing pattern of high-level E/M codes exceeded two standard deviations above the mean for their assigned marketplace were issued a notice of termination per Aetna. As a result, CMA sent a letter to Aetna outlining a number of serious concerns regarding this initiative, including the following: Patients’ access to care may be unnecessarily jeopardized if physicians are not offered a meaningful opportunity to appeal or address the underlying issue prior to physician termination from the network. The inappropriateness of terminating physicians who billed outside the norm with respect to higher level E/M codes, without any prior-notice or opportunity to correct or explain the medical necessity of the care at issue, or to appeal the termination. The termination of physicians based solely on their billing levels without first engaging them to discuss factors that may have led to higher than average billing, such as physicians treating a sicker patient base (e.g., HIV patients or seniors with underlying conditions), thereby wrongly punishing providers who treat these most vulnerable patients. While physicians have been advised by Aetna of the right to request both a reconsideration of the Aetna E/M findings as well the ability to submit a separate appeal of their termination from the Aetna network, both processes failed to advise physicians of what information Aetna would consider relevant for review of this issue. However, feedback to CMA from physicians who were successful in the appeal of their termination highlighted valid reasons why their billing patterns differed from the norm, including being an urgent care practice or serving a high-risk population. This underscores the need for physicians and their staff to carefully read all payor correspondence; ensure contractual notices of any kind are immediately routed to the physician for review and response; and call CMA with any questions. Physicians impacted by the Aetna termination are encouraged to contact CMA at (916) 551-2865 or mlane@cmanet.org for additional assistance. July 6, 2015 General Billing/Coding, Coding and Documentation, Practice Resources, Aetna 0 0 Comment Read More »
Online tool that gives consumers average costs for over 70 medical procedures now live A new online tool that gives consumers an idea of the cost for several health care procedures went live last week. Launched by the Health Care Cost Institute (HCCI), an independent, non-partisan, non-profit organization, Guroo.com shows average amounts paid for over 70 common care episodes in most states, including much of California. Using data supplied by Aetna, Assurant Health, Humana and UnitedHealthcare, the website pulls cost information from the medical claims of more than 40 million U.S. residents. According to HCCI, the prices are averages of the total payments to providers (i.e., what the patients pays plus what the health plan pays) on adjudicated claims by geographic area. The information is put in consumer-friendly terms, with all the cost ranges provided for medical care that is “shoppable” – generally meaning it is elective and can be scheduled in advance. The new website is free and accessible to consumers, regardless of their insurance status or insurance company. The information is presented using care bundles (e.g., knee replacement, hip replacement) and summarizes the steps of care (when appropriate), showing the cost of each step. The tool also provides consumers with questions they can use when talking with their health care providers to better understand their choices and help achieve a quality health outcome. Although Guroo.com was designed specifically for consumers, HCCI hopes that this website will also be valuable to employers, policymakers and regulators who can now assess prices and compare costs nationally and locally. HCCI said it also aims to help consumers learn more about their health care conditions, including the common progression or likely steps of care, what to expect and how to prepare for their doctor visit. While the tool does not yet give provider-specific prices, within a year HCCI expects to let members of UnitedHealthcare, Aetna, Assurant and Humana track spending on a companion site and check how switching caregivers could lower their out-of-pocket costs. Currently, the database populating the website contains approximately 3 billion claim lines and will be adding 214 care bundles in June. HCCI says that before the end of 2015, it hopes to grow the database to contain claims data from over 100 million Americans, with the addition of Medicare claims data, making it the largest public database of its kind. The website will also add a quality of care feature in the future, though HCCI is still in the early stages of planning the quality component. Under a federal grant, the California Department of Insurance is continuing to pursue the development of a similar database, though on a much smaller scale, called the California Online Medical Price and Quality Transparency (COMPAQT) initiative. The COMPAQT website currently is scheduled to go online this year, providing cost and quality ratings around five health conditions. Considering the potential for databases such as these to be used by more patients over the next year, physician practices may want to familiarize themselves with the information being provided on websites such as Guroo.com. Because the cost information provided on Guroo.com depends largely on the allowable amounts paid by the aforementioned insurers, it may differ significantly with the billed charges quoted to any particular patient and lead to a desire for more information from the patient on the cost of a service, particularly for those patients who may still be under their deductible. Contact: Brett Johnson, (800) 786-4262 or bjohnson@cmanet.org. March 2, 2015 General Insurance, United Healthcare, Aetna 0 0 Comment Read More »
Aetna seeks to terminate its proposed $120 million class settlement over use of Ingenix to underpay out-of-network claims Late last year, Aetna, Inc. announced a proposed class settlement of up to $120 million over its use of the flawed Ingenix database. The nationwide settlement would have required Aetna to reimburse providers and Aetna PPO subscribers for losses arising from Aetna's underpayment for out-of-network medical care. A hearing had been scheduled for March 18, 2014, in the U.S. District Court in New Jersey for the court to determine whether final approval of the settlement should be granted. Less than a week before the hearing, however, Aetna notified the court it was invoking a provision of the settlement that gave the insurer the right to terminate the agreement if the settlement claims of providers and subscribers opting out of the settlement exceeded $20 million. Aetna told the court, "Based on the list of Opt-Outs provided by the Settlement Administrator to Aetna and Class Counsel, the Opt-Out levels exceed the threshold." Aetna did not provide specific numbers. The creator of Ingenix, United Healthcare, entered into a $350 million class settlement in 2009 for systematic underpayment of out-of-network claims. The New York Attorney General investigated United and Ingenix and concluded that the database was rigged to understate the value of medical services. The Attorney General settled with United and more than a dozen other health insurers, including Aetna, over their use of the database. Counsel for the settling plaintiff class is in the process of determining whether Aetna has properly terminated the settlement. Assuming it was properly terminated, the class action lawsuits against Aetna will resume toward trial. The California Medical Association (CMA), the American Medical Association and numerous other state medical societies also had sued Aetna over its use of Ingenix but were not parties to this settlement agreement. The medical societies' claims were dismissed after a federal court in Miami determined they were barred under earlier settlements reached with Aetna in 2005 over federal RICO claims. That court's decision is currently on appeal. Contact: CMA Center for Legal Affairs, (800) 786-4262 or legalinfo@cmanet.org. March 27, 2014 General Ingenix, Insurance/Reimbursement, Legal Advocacy, Aetna 0 0 Comment Read More »
Online payment portals: Physicians beware Recently, a number of payors have begun to offer online payment portals that allow patients to pay for physician services via the Internet. Physicians should be aware, however, that while these online payment portals typically do not charge setup fees for participating, physicians will be assessed a per transaction fee, similar to the transaction fees associated with credit card or merchant transactions. Aetna, for example, partnered with Citi to provide an online patient health care payment option called Money² for Health. This online payment tool will allow patients to securely pay for physician services through the Aetna Navigator member website. For physicians who have signed up to participate in Money² for Health, patient payments will be electronically transferred into your designated accounts. United Healthcare (UHC) has also recently instituted a similar online portal through Instamed. Through the myClaims Manager selection on the www.myuhc.com website, members can now elect to make payments to their medical providers. Physicians should also be aware that non-participation in these programs does not necessarily prohibit patients from continuing to pay through the portal. For instance, the UHC/Instamed program will still allow patients to make payments to physicians who have chosen to not participate in the program. In lieu of an electronic funds transfer to the physician’s bank account, Instamed will issue a hardcopy check to the physician instead. However, the issuance of the hardcopy check does not alleviate the physician from being required to pay a reduced transaction fee. CMA has inquired further with United about physician options to avoid any transaction fees. November 18, 2013 General Payment Plan, United Healthcare, Aetna 0 0 Comment Read More »
Plan departures leave questions for California policy holders While much attention has been given to the successful signing of health plans participating in Covered California’s new online insurance marketplace, it’s worth noting that some major players in the state’s current insurance market are refusing to play ball. In June, both United Healthcare and Aetna announced that they would not be participating in California’s individual market following the end of 2013. In announcing their departures, both companies noted that only a small portion of their overall business was conducted in California, and given the coming changes promised through the Affordable Care Act (ACA), no longer found it viable to offer plans in the state. Both firm’s decisions apply to the state’s individual market as a whole, not simply the portion that would be served by the exchange. United and Aetna currently make up 2 percent and 5 percent of the state’s individual market, respectively, together covering just shy of 60,000 Californians. While some observers are using the departure of United and Aetna to condemn the ACA, claiming that the increased regulation of the market in California forced the insurers out of state, others are more curious about how the smaller, regional plans will help absorb the roughly 60,000 residents who previously purchased covered through the two soon-to-be-departed firms. These plans, such as L.A. Care Health Plan, Valley Health Plan and Chinese Community Health plan are relatively unknown to the majority of Californians, but could play a large role in providing coverage to residents through the exchange beginning in 2014. In other departure news, Anthem Blue Cross announced last month that it would not be participating in Covered California’s Small Business Health Options Program (SHOP), the exchange’s small group marketplace, for at least the first year. Anthem’s decision to remain on the sidelines could potentially be a bigger issue than Aetna and United’s refusal to participate in the individual market. Recent estimates suggest that Anthem represents roughly a third of California’s small group market. With plans selected to offer products on SHOP beginning in 2014, it will be interesting to see who is willing and able to take up such a massive market share left behind as a result of Anthem’s departure. August 19, 2013 General Covered California, United Healthcare, Aetna, Health Care Reform 0 0 Comment Read More »
