Tuesday, April 10, 2007

UnitedHealth's Self-Referral

The line has been crossed. UnitedHealth, the health largest insurance provider in America, not only has officially decided who, when and where patients should get care, they've decided that if physician's don't comply, they'll be fined and removed from their network, forcing patients to switch providers:
(WSJ) Most health plans are designed so their members pay more when they go to an out-of-network doctor or take a nonpreferred medication. But the financial sanctions -- which UnitedHealth has yet to impose -- mark the first time a physician could be fined by a health insurer if he or she directs a patient to seek out-of-network care or testing, the American Medical Association says.

The threats stem from a 10-year deal that UnitedHealth struck late last year with Laboratory Corp. of America Holdings to become its national in-network laboratory. With 28.5 million health-plan members and growing, UnitedHealth has been using its heft more and more in recent years to negotiate cut-rate fees with doctors, drug makers and other suppliers. In the same vein, it signed on Lab Corp. after its longtime lab partner, Quest Diagnostics Inc., said it couldn't accept new terms that UnitedHealth wanted and dropped out of contract negotiations.

To squeeze as much savings as possible out of the Lab Corp. deal, UnitedHealth sent a not-so-friendly reminder to doctors to play along. If doctors consistently failed to refer patients to Lab Corp. or other local in-network lab facilities as of March 1, UnitedHealth said it reserved the right to fine them $50, cut their fees or oust them from the network.
Is this where we're going to cut health care costs in America? Fine the doctor. As if we set the lab prices. Is the monopolization and WalMart-ization of health care always in the patient's best interest? Or could there just be, in the interest of corporate profits, an ulterior motive? I can just see UnitedHealth's Directors and Board Members sitting around the board room table:
Hey Donna! I gotta idea how the heck we can pay for ol' McGuire's accountant fees and post-retirement corporate jet! We'll just tack on a fine to those pesky physicians! Imagine. 520,000 of 'em ordering way too many tests, say twenty a day, about five of which we can find as improper, times fifty bucks. Hell, that'd be a cool $130 mil! Yeeeeeee Haaaaaa! That'd pay for his jet with a little left over for us! Whatd'ya think, girl?"

"Oh Steve, I love it when you talk dirty!"
I love the double standard. Physicians can't refer to their labs due to concerns over conflicts of interest due to the Stark laws, but insurers can help themselves and do even one better: threaten physicians if they fail to make such a financially-motivated referral that lines the insurance company's coffers.

Oh, but certain self-interested physicians don't seem to mind, especially those in leadership positions poised to profit:
Not all doctors are upset. The American Academy of Family Physicians wrote a letter of concern to UnitedHealth in February. But it told members that the health insurer had eased its worries after clarifying that it would not punish doctors for patient's decisions and only apply the sanctions in rare cases where a doctor repeatedly defied the policy. "This doesn't look as bad as it originally did," says Bruce Bagley, the academy's medical director for quality and improvement. Dr. Bagley also serves on a physician-advisory committee for UnitedHealth.
I wonder how much they payed Dr. Bagley for his time to sit on their committee?

-Wes

6 comments:

: Joseph j7uy5 said...

IANAL (I am not a lawyer) but this sounds like an anticompetitive policy, potentially raising antitrust issues. Whether it is legal or not, it is unethical. Plus, how are they to know if it was the patient who decided to go to a particular lab, or the MD who suggested it? Trying to enforce something that is not objectively verifiable seems like a dumb policy.

Plus, there may be clinical reasons for referring a patient to a specific lab. I tend to refer patients to the lab that gets the reports to me the fastest, and is most reliable about getting me the reports.

But if a patient or family member works at the lab, or has access to the lab results, I will send the patient somewhere else. I do not like the idea of getting fined for doing something that is clinically justified.

Anonymous said...

It's time that "private practice" physicians finally realize that they are no longer independent practitioners of medicine. You are contractors of the insurance companies you sign up with. If you don't like the terms, either re-negotiate or cancel. It's just like a credit card company that raises its interest rate and fees. If you don't like it, tear up the card. Stick your head out of your office door and yell, "I'm mad as hell and I'm not gonna take it anymore." See how many employers stick with United once their provider lists shrink to a few names. Yes, a lot of doctors will temporarily lose patients and income. You will never change things unless you are willing to sacrifice a little and fight.

Jillyflower said...

We dropped the PPO's in our practice last summer. Yes, we have lost insurance patients but the ones we have lost are the same ones that would be mad because our fees were above UCR, or because we sent them a bill because their insurance didn't pay, or better yet, because they never paid and we had to send them to collections. Let's hire a few management consultants on top of that, oh and how about the fact that the doctors offices are so kind that they hire staff to figure out the insurance benefits for their patients, only to be wrong because the rules change all the time so then, the patients are mad at the DOCTOR because of what their INSURANCE PLAN DOESN'T COVER!!!!!

Thanks, but kiss my ass.

Now, all of the treatment in our office is paid in advance before treatment begins. No insurance companies, no billing messes, collections, and on and on. The pace is better, we have NO administrative staff anymore (I can run a credit card) and I answer my own phone.

Insurance companies think that the only way doctors can get patients is through their plans. Doctors, get a blog, make an effort to connect with your patients (Permission Marketing by Seth Godin is a great place to start) explain to your patients what greedy bastards the insurance company execs are (in politically correct language of course) and then FIRE the insurance companies. The consumer deserves to have their hard earned dollars spent on their healthcare, not on administrative hassles and excessive CEO pay.

Sacrifice and fight my friends - don't sign up for PPO plans, don't accept assignment of benefits, have patients pay for their services up front and let the free market system dictate your fees, which may require some adjustments. But hey, when collections = production and the hassle is gone, their might actually time to take care of the patients like you imagined it would be in school!

TBTAM said...

This is a fabulous post - you've single-handedly outlined every reason why United Health care and the AAFP)are so wrong in this.

Nancy Hoffman said...

I just read an article that says, “Hospital executives rank United Healthcare as the worst insurance company in the United States.” That does not surprise me in the least after reading the many negative reviews about them on the internet.

I am a neuropsychologist and was asked to see a UHC member for neuropsychological testing. I filled out all of the appropriate forms required by United Healthcare and received a telephone call authorizing me to test their member. They gave me a cap on the hours (13 hours total) and an authorization number. I provided the services as promised and then sent the appropriate claim to the United Healthcare offices. When they sent me the check, there was a note on the Explanation of Benefits saying I had agreed to a discounted fee (an approximately 50% discount, mind you) through an organization called MultiPlan (If you haven't heard of them, you're in for a treat. They contract with insurance companies to try to persuade clinicians to agree to a reduced fee and they get paid a percentage of what they "save" the insurance company.) Needless to say, I do not and never will have an agreement with this company, as I do not support business practices such as this.

When I contacted United Healthcare to straighten this out, they told me I had to deal with MultiPlan. Multiplan never answers their phone (I wonder why) so I got nowhere until I filed a complaint with the Better Business Bureau. This got the attention of Cindy Hernandez, a Consumer Affairs Advocate for UHC (1-800-842-2656). She researched this issue and came up with a fabulous solution! She decided that United Healthcare had authorized this treatment in error and paid me in error AFTER I HAD RENDERED THE AUTHORIZED TREATMENT to their member. They then "recalculated" the claim form and decided that I actually owe THEM money! They have asked for the entire amount back ($966.68). They have a very fancy way of explaining their "logic" and have added that the original error was with their processor and they have arranged for her "to receive additional training or other intervention as appropriate."

With a second patient, they attempted to get me to accept a reduced fee through MultiPlan for another member and I declined. After that, they refused to pay me AT ALL for the services I provided to the other member while he was in the hospital. United Healthcare also authorized these services and the correct authorization number was submitted with the claims.

In both cases the services were requested by a physician and approved by United Healthcare. The services were rendered as authorized and the appropriate claims were filed. Unfortunately – and this really is the sad part – both of these claims will have to be paid in full by the members. These claims total thousands of dollars.

United Healthcare is the focus of a Class Action Lawsuit in New York because of their questionable business practices. When I Googled “United Health Care reviews,” I was SHOCKED at the number of complaints against this company. How is it that they are getting away with this kind of behavior?

Nancy Hoffman said...

I am a neuropsychologist and was asked to see a UHC member for neuropsychological testing. I filled out all of the appropriate forms required by United Healthcare and received a telephone call authorizing me to test their member. They gave me a cap on the hours (13 hours total) and an authorization number. I provided the services as promised and then sent the appropriate claim to the United Healthcare offices. When they sent me the check, there was a note on the Explanation of Benefits saying I had agreed to a discounted fee (an approximately 50% discount, mind you) through an organization called MultiPlan (If you haven't heard of them, you're in for a treat. They contract with insurance companies to try to persuade clinicians to agree to a reduced fee and they get paid a percentage of what they "save" the insurance company.) Needless to say, I do not and never will have an agreement with this company, as I do not support business practices such as this.

When I contacted United Healthcare to straighten this out, they told me I had to deal with MultiPlan. Multiplan never answers their phone (I wonder why) so I got nowhere until I filed a complaint with the Better Business Bureau. This got the attention of Cindy Hernandez, a Consumer Affairs Advocate for UHC (1-800-842-2656). She researched this issue and came up with a fabulous solution! She decided that United Healthcare had authorized this treatment in error and paid me in error AFTER I HAD RENDERED THE AUTHORIZED TREATMENT to their member. They then "recalculated" the claim form and decided that I actually owe THEM money! They have asked for the entire amount back ($966.68). They have a very fancy way of explaining their "logic" and have added that the original error was with their processor and they have arranged for her "to receive additional training or other intervention as appropriate."


Unfortunately – and this really is the sad part – the claim will have to be paid in full by the member.

When I Googled “United Health Care reviews,” I was SHOCKED at the number of complaints against this company. How is it that they are getting away with this kind of behavior?