Physicians Education Corner:
The Wyoming Medicaid Program found (through compliance AUDIT) to have underpaid physicians since contracting to their "claim administrator", as their claim system could not "read" any modifiers, causing physician services to be denied in error.... Wyoming FP provider received over $120,000.00 (6-8/2008) in back MEDICAID Program payments after 2 1/2 year claim audit project by APPS. "WERE YOU ALSO ENTITLED TO AUDITED PAYMENT due to practicing in the State of Wyoming?" We are still questioning claim processing since 1998 due to modifier recognition problems for Wyoming Providers through CMS out of Denver, Colorado. Call us to day for more information.
Arizona United HealthCare Medical Director noted to say, "we are interested in CHEAP HealthCare, not Quality HealthCare".
Phoenix Arizona, a family practice physician changes the way he provided medication managment to his patients upon continued statistical badgering by United HealthCare. Patients were scheduled from monthly visits to quarterly visits, without a quality-of-care problem arising, savings United HealthCare an estimated $460.00/per member/ per year. Physicians actions noted as "not good enough per United HealthCare", physician continually threatened with his contract retention. With his contract up for renewal in October 2006, and United HealthCare's continued badgering with unsubstantiated peer physician statistics suggesting provider is overcoding, the physician looks to state laws and physician organizations to protect him. When the physician explains his services are all subjected to CERTIFIED (CPC) compliance audit, United HealthCare turns a deaf ear to the provider. Will no physician organization step forward and offer protection to physicians? This physician TERMINATES his contract with UHC and opens his practice to NEW PATIENTS with other insurance coverage. The practice is still FULL each day and the physician continues to provide quality patient care.
So, United Health Care purchased Pacificare for over 8Billion, Then Great West. WHY, when less than six years ago UHC and AETNA both cancelled their Medicare Replacement Product sales, due to such poor profits? What is UHC thinking now? Are operational expenses that CHEAP outside the USA, even with the mistakes being made in provider claim/payment determinations and with the additional cost of claims needing to be reprocessed correctly from within the USA a second time? So why is HealthNet working USA physician claims from Jamaica?
*** After 13 years as a Certified Professional Coder with the American Academy of Professional coders out of Salt Lake City Utah, Co-Founder of the three AAPC Chapters in the Phoenix Arizona/Past President, and working to help physicians recognize the value of other certified medical professionals, I have chosen not to retain this certification due to the 10/2/06 purchase of the AAPC by EliResearch (with their parent corporation located in Florida) Being double certified I have the ability to redirect my energy to the more educationally positive organization: "Practice Management Institute", out of San Antonio Texas.
Researching EliResearch through the State of Florida Better Business Bureau and the State of Florida Attorney General's office I found the parent corporation to be ethically questionable. Please call or email me for more information.-Debbie Fehr, CMC (Certified Medical Coder)
WHY IS PATIENT INFORMATION BEING SENT OUT OF COUNTRY FOR CLAIM PROCESSING? WHAT HAPPENED TO HIPAA PRIVACY & SECURITY?
1. "just trying to get to the bottom of the patient's copay I received four (4) separate amounts from HEALTHNET, depending upon whom answered their phone. Did you know a Healthnet provider relations staff stated their PPO and POS products view Family Practice level Providers as PCP's either in-network or out-of-network for copay assessment at either $10 or $20, but for their Medicare and HMO products the Family Practice level providers are viewed as SPECIALISTS, with patients responsible for the higher end copays if either in-network or out-of-network at $35 or $40. Has anyone asked MEDICARE if this can be interpreted as "discrimination"?
2. Do you know at least Pacificare and Humana have been performing physician audits called "Medicare RISK" audits, where through full open patient chart access their independent certified coding auditor will review diagnostic test results, and for additional PAYMENT from the MEDICARE program these auditors will CHANGE patient diagnosis codes. MEDICARE has just started paying MEDICARE replacement policy carriers on the reported DIAGNOSIS code. If there is more revenue to be made from reporting a diagnosis code other than the coding reported by the physician, the diagnosis coding has been changed. REMEMBER: the goal behind "Fraud/Abuse" actions is stated as MONETARY GAIN! So, What is a patient, or the patient's physician to do when an insurance carrier starts altering claim data and independently accesses patient diagnosis data??? Questioning this with HIPAA, I was referred to the OIG.
3. Even though purchased by United Health Care is your contract with Pacificare still directing your claim processing out-of-country to Ireland?
4. Is your contract with United Health Care (INGENIX) still directing your claim processing out-of-country to India, or have they relocated to the Philippines or back within the US for some select physician group contracts?
5. Is your contract with HealthNet still directing your claim processing out-of-country to South Africa?
6. Speaking of insurance carriers, do you know the American Medical Association may contract with United Health Care (INGENIX) to publish CPT-4 annually? Are the CPT-4 Books then being printed in India?
7. Do you know the parent corporation of INGENIX is United Health Care? Do you send staff to conferences to learn coding and billing standards conducted by UHC? Does some of the UHC/INGENIX contract work define conflict-of-interest?
8. Do you question the HIPAA validity of routing your patient confidential claim information out-of-country for payment evaluation?
9. Do you question "conflict-of-interest" with regards to INGENIX and their parent corporation United Health Care?
10. Why are you still "UNDERCODING" your services to patients to "play-it-safe"? Are you using DOCUMENTATION TEMPLATES to help capture your documentation and save your level four and five E&M services? WHY as providers, do you continue to let Insurance Carriers intimidate you and control your medical treatment plans for your patients? APPS CONTRACTED PROVIDERS GET PAID THE FULL CONTRACTED VALUE OF THEIR SERVICES, DO YOU? The secret is "an insurance carrier has no ability to intimidate or control an outsourced COMPLIANCE partner of yours. How can your contract be put in jeopardy for your being "COMPLIANT". Become a contracted compliance partner today!
Have you contacted your state representatives and questioned "conflict-of-interest" related to these questions? How can you survive in this industry if financial gain is openly biased toward the insurance carriers? You need to align yourself with professionals that will advocate on your behalf and for your benefit. Which states are actively advocating to stop export of your confidential patient claim information to other countries? Don't you want to know???? -df
Do You Know The Profits Reported By Major Insurance Carriers For The Fiscal Year 2003, 2004, 2005 or 2006? What are they projecting for 2007 and 2008. It is all revenue out-of-the medical service provider's pocket.
For similar information go to the Jeanne Scottletter, jeanne.scott@health-politics.com