ASAM and announced a collaborative effort with Brandeis University to test and validate three ASAM performance measures for addictions treatment. ASAM hopes that this project will provide measure testing of performance measures that will be accepted and adopted in the treatment of patients with addiction.
Three measures will be tested using two years of de-identified Cigna claims data for substance abuse. The measures to be tested in the study will be: use of pharmacotherapy for individuals with alcohol use disorders; pharmacotherapy for individuals with opioid use disorders and follow-up after withdrawal. This is expected to be a six month project. Continue reading →
Addiction treatment providers continue to react to an assault by payers to run them “out of town.” The first round of attacks (in the Fall of 2014) focused on the practice of copay and deductible write offs. The phrase cooked up by lawyers for Cigna, “fee forgiveness,” wound its way into the courts system in Texas in a case (Cigna v. Humble Surgical Hospital, Civ. Action No. 4:13-CV-3291, U.S. Dist. Ct., S.D. Tex., Houston Division) against a surgery center, where Cigna argued that the practice of a physician owned hospital in waiving “patient responsibility” relieved the insurer from paying ANYTHING for services needed by patients and provided to them. Though the case did not involve addiction treatment providers, it gave addiction treatment lawyers a look into what was going to come. The same argument made in the Texas case was the initial attack by Cigna in a broad attack of the addiction treatment industry, especially in Florida.
As addiction treatment providers fielded Cigna’s “fee forgiveness” attack in the context of “audits,” providers held firm to the belief that justice would prevail and that they would soon restore a growing need for cash flow. “If we just show them that we’re doing the right thing,” providers thought, “surely they will loosen up the purse strings.” After all, this was a patient population in terrific need of help, with certain [untested] protection by federal law (the Mental Health Parity Act). Continue reading →
One of the most commonly overlooked components of a managed care contract is the definitions section despite the fact that what is contained here will affect the contracted provider on a daily basis. Contract terms that are too generic so that they are not clearly defined and understood as they relate to a particular area of practice can have a direct influence on clinical decision making. A patient may need a higher level of care but be approved for a lower level only. The provider knows that a patient may suffer if the level approved will not treat the illness or that the patient’s condition could deteriorate without a higher level of care.
Let’s take, for example, the definition of medical necessity in a contract. Who decides medical necessity? Is it the provider or is it the managed care organization (MCO)? Many contracts state that the term “medical necessity” relates only to the issue of reimbursement. Further, that the approval or denial of a claim is “for reimbursement purposes only” and should not affect the provider’s judgment on whether treatment is appropriate to treat the illness, symptoms or complaints of the patient. Continue reading →
By now, it’s not news in Florida that drug and alcohol recovery providers are staring devastation in the face as payers continue to mount non-payment offensives. As payers one by one march on the industry and starve providers of cash flow for operations, many providers can be expected to shut down. To make matters worse, as the popular media continues to act as a conduit for gross misrepresentations of industry providers, the public’s affection for the industry can’t be expected to improve. This makes the future look especially bleak for the industry, and yet the silence and stillness of providers is baffling.
Given the breadth of the payer problem (many simply aren’t paying providers), why are we not seeing a slew of lawsuits filed by providers? In nearly 30 years as a Florida healthcare lawyer, I’ve never seen a healthcare sector so hammered by insurance companies. And I’ve never seen it unanswered in court. Continue reading →
Media reports regarding the treatment industry and Cigna’s announcement go unquestioned by reporters. For instance, the Palm Beach Post article claims “the sky-high charges have exploited addicts and alcoholics seeking help, gouged insurers and spurred law enforcement interest….” It pictures a young, tattooed man as a recovery business owner, but does not mention any wrongdoing or charges against him. It restates claims in a lawsuit against a toxicology lab without any counterbalancing input from the lab that is the subject of the lawsuit. It expresses certainty that insurers are being gouged, but does not mention that the rates actually paid by insurers for out of network services are determined entirely by the insurers, not the treatment providers. It’s an article full of allegations and innuendos, but no meaningful coverage of any of the issues. Continue reading →
While your healthcare business may be compliant with billing regulations and coding, this does not mean that your payer is compliant and has paid you correctly per your contract. Providers know that Fraud and Abuse has been one of the largest areas of focus for payers and the government over the past 20 years. Due to this attention, many healthcare businesses engage auditors to audit their compliance of claims quarterly or annually. However, in addition to compliance audits, a provider should be auditing their payer interaction to create a dynamic blueprint of denial management and payment recovery. The AMA states that a 5% denial rate for an average family practice equates to about $30,000 walking of the door. A good benchmark for payer compliance would be a denial rate of 5-10%. Often times, practices and healthcare businesses operate with a much higher rate, and even in the 20-30% range without even knowing it.
When auditing the payer interaction, several components should be included in the review including:
Denial rate percentage
Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period as an Aggregate
Aging of claims paid for 30 day, 60 day, 90 day, over 120 day period by each Payer
Claims denied categorized by denial reason as an Aggregate for previous 12 months
Claims denied categorized by denial reason by each Payer for previous 12 months
Claims that have been appealed, the date submitted, the date of the outcome, the outcome by each Payer
Claims not paid according to fee schedule as an Aggregate for previous 12 months
Claims not paid according to fee schedule by each Payer for previous 12 months
There is nothing readily understood about the term medical necessity. In healthcare it is the “overarching criterion for payment”. There is no payment for services or supplies if there is no medical necessity to support it. Today, every provider at some time is faced with a denial because of lack of medical necessity. Physician providers will usually hear that payors do not get in the way of the physician-patient relationship. Payors typically state that they never tell a physician how to practice medicine and a denial based on lack of medical necessity is for purposes of payment only. However, what provider, on a routine basis, will continue to order care and services which medically unacceptable and not supported for payment purposes?
The definition of medical necessity varies from one commercial plan to another. Federal law such as Medicare has its definition and so does state law under programs such as Medicaid. Various medical associations such as the AMA also define medical necessity.
Generally, medical necessity refers to services or supplies which are required for the treatment of an illness, injury, diseased condition or impairment and which is consistent with a patient’s diagnosis or symptoms and are in accordance with generally accepted standards of medical practice. Services or supplies must not be ordered only as a convenience to the patient or provider. Of course care and services which are investigational or unproven are not considered medically necessary. Continue reading →