APMA News - July 2011 - (Page 40)

Can They Really Do That? By Laura Pickard, DPM FAQs about Private Insurance Contracting Over the last decade, the Health Systems Committee has responded to many different insurance questions. Frequently, the answers depend on plan-specific or state-specific factors such as the state health insurance environment, state healthcare laws, and provider rights under a given plan’s contract. However, there have been many basic, repeated questions. Although the Health Systems Committee rarely can give members black and white answers, we will review frequently asked questions in this new five-part series, along with the methodology APMA has developed to resolve these issues. Our goal is to provide practical advice for APMA members. QUESTION: Can insurance plans have different fee schedules for different types of providers? ANSWER: Unless they are prohibited from doing so under applicable law, insurers or other payers can have different fee schedules for different types of providers. To determine whether a particular plan can have a different fee schedule for podiatrists, you must first understand what type of insurance plan you are dealing with and what laws and regulations apply to that plan. As background, insurance companies and other payers may have hundreds or thousands of provider contracts. Even within a particular provider specialty, these contracts may have distinct fee schedules resulting in different amounts paid for the same service depending on the provider. Differences in payment may be based on a variety of factors that frequently relate to negotiating strength, such as a group or IPA’s market power, the need to include a physician located in a particular geographic location, or the need to include a specific physician specialty that is underrepresented. Other differences may arise because of the inclusion of supplemental payments such as quality bonuses. When the difference in payment amount is based solely on the fact that the physician is a podiatrist rather than an MD or DO, APMA views this difference as fee discrimination. Few states have laws preventing this type of discrimination. To address this issue, APMA, through the State Advocacy and Health Systems Committees, developed the Model Fee Parity Law Project. It is a tremendous resource that tries to help individual state components sift through their members’ insurance issues related to varying fee schedules. To effectively end fee discrimination, the Model Fee Parity Law recommends three different types of antidiscrimination protection for state implementation—protection against discrimination in coverage of services furnished by podiatrists, in participation in health networks, and protection against fee discrimination. This valuable tool can be found at www.apma.org/modellaws. 40 APMA News July/August 2011 Many states do have antidiscrimination laws, but most are missing some of the recommended protections. Moreover, it is important to keep in mind that such state laws only apply to a subset of health plans. For example, a state law prohibiting fee discrimination would generally be pre-empted in the case of individuals covered under the Federal Employees Health Benefits Program, a military health care program, or Medicare (whether under Medicare fee-for-service or a Medicare Advantage plan). In addition, state law generally is pre-empted as it applies to self-insured employer group health plans. Therefore, these plans are not obligated to abide by state insurance antidiscrimination laws, any willing provider laws, or even state recoupment laws. An employer group health plan is self-insured if the employer assumes the financial responsibility to pay health claims for its employees. It is important to keep in mind that many self-insured plans use third party administrators to perform the administrative duties of the plan. Therefore, even though the plan is self-insured, its membership card may contain the logo of the health plan that administers it for the employer. An employer group health plan is insured if an employer pays a premium to an insurer, which then assumes the financial risk for providing or paying for the health services. Under the Employee Retirement Income Security Act, state laws are enforceable against the insurers of insured employer group plans if the laws are viewed as regulating the “business of insurance.” As a practical matter, what can you do if you don’t like a particular fee schedule or suspect that a plan is engaging in fee discrimination? First, determine whether fee discrimination is prohibited under state law. If it is, assert your legal rights to the insurer, or if the insurer is unreceptive, to the state agency responsible for enforcing the law (frequently the department of insurance). The Model Fee Parity Law Project provides detailed instructions regarding how to look up, understand, and obtain enforcement of antidiscrimination laws. If there is no such law (or the issue is simply an unsatisfactory fee schedule), you can try to negotiate the payment rate offered under the contract. Chapter 2 of APMA’s Private Insurance Resource Guide can give you insight into what you need to ask for in your contract and the possible repercussions of typical contract language. Access the Private Insurance Resource Guide at www.apma.org/PIRG. You must be your own advocate! If your efforts are unsuccessful, you must evaluate your office profit/loss ratio for that particular insurance plan. No one but you can assess this. Can you survive without participation in the plan or do you need the insurance participation to survive? Every practitioner’s situation is unique. n APMA Trustee Dr. Pickard is chair of the Health Systems Committee and can be reached at ljpickard@ apma.org. http://www.apma.org/YourPractice/content.cfm?ItemNumber=1280 http://www.apma.org/workingforyou/content.cfm?ItemNumber=1306&navItemNumber=665

Table of Contents for the Digital Edition of APMA News - July 2011

APMA News - July 2011
President’s Message
Contents
PICA Reflects on its Past, Looks to the Future
APMA Media Event Wrap-Up: Toning Shoes Are All The Rage, Along with Podiatrists' Expert Advice
APMA Member Testifi es Before Congressional Committee on Health IT
Stepping Up to Prevent Falls: Part II
Resident Experts: CPME's Residency Evaluators Share Their Stories
Strategic Planning Retreat Underscores APMA Direction
Reimbursement
Can They Really Do That?
Members Who Know Media
Technofile
Young Voices
Federal Advocacy Forum
Small Business 101
CPME Update
APMAPAC Chair Report
APMA All Stars
In Short
Worthy of Note
Affiliates Corner
Insurance Advisor
New Members
Death Notices
APMAPAC Update
Development Update
Annual Scientific Meeting Sponsors
Committee Nominations
Bylaws Propositions Due
Classified Advertising
Dates to Remember
Advertising Index
Ten Questions

APMA News - July 2011