Private Payer News
Please select the links below for complete Private Payer articles and events of the current year. View Private Payer Archives
05.19.08 Video Educates Physicians About 'Cost of Care'
The Physicians Advocacy Institute (PAI), has produced a video called "Understanding Episodes of Care," which carries with it 3 CME credits. This video is intended to educate physicians about the intricacies of this latest methodology that rates physicians' "efficiency," most commonly known as "cost of care." It defines pertinent terminology and explains how the ETG methodology works. After completing this course, it is anticipated that physicians will be armed with the information they need to engage health plans in meaningful dialogue about the quality of care decisions and advocacy that physicians undertake on behalf of their patients.
Click Here for Video
05.01.08 AMA Announces Cure for Claims Month: Coming in November 2008
MAG invites its members to join the AMA Practice Management Center’s (PMC) effort to help physicians fight for accurate health care claims payments and reduce the administrative costs involved in submitting claims.
Cure for Claims Month is a campaign to heal the health care claims process and cut the national average of what physician practices spend on submitting claims from 10 to 18 percent to just 1 percent. The campaign urges physicians and their practices to – in November when many health insurers unfairly hold back claims payment – hold payers accountable by reviewing and auditing claims for accuracy.
Members can visit www.ama-assn.org/go/pmc to use the PMC’s online educational materials and tools. The PMC Web site offers a number of resources covering every aspect of managing a physician practice, ranging from contracting with insurers and setting a fee schedule to working through appeals and collections.
Visit the PMC's Web site
03.04.08 MAG’s Third Party Payer Advocacy Has Saved Members $3.5 Million in 2008 By Convincing BCBSGA to Allow Modifier-25 with Code 69210
Effective May 1, 2008, Blue Cross Blue Shield of Georgia (BCBSGA) will begin allowing modifier-25 with procedure code 69210 (Removal impacted cerumen) in addition to the E&M visit. This change is a result of the involvement from MAG’s Department of Third Party Payer Advocacy on behalf of a member.
During 2008, this change will represent payments of an estimated $3,528,000 for the 147 MAG Members who are Otolaryngologists. Statewide, MAG’s Department of Third Party Payer projects that ENTs will receive more than $19 million for this procedure from BCBSGA in 2008 alone.
Please contact the Department at 678.303.9274 or tbaptiste@mag.org if you require third party payer assistance.
02.28.08 Aetna Announces Delay in Implementation of New Clinical Policy
Aetna today announced that it will delay the effective date of a new clinical policy addressing the medical necessity of an anesthesiologist’s services during routine upper and lower endoscopic procedures, such as a colonoscopy. MAG's Department of Third Party Payer Advocacy had been arguing against the new clinical policy. Aetna has always covered moderate sedation, which is delivered by the treating physician, and is the type of sedation used for the majority of colonoscopies across the country. In the new policy, which was announced in late December, Aetna continues to cover moderate sedation, but only covers monitored anesthesia care for high-risk patients. The policy was scheduled to be effective on April 1, 2008. Aetna will now delay implementation until patient-friendly alternatives – which will not require the added expense of an anesthesiologist – are approved by the Food and Drug Administration (FDA) and available in the marketplace.
Read Aetna's Press Release
Read Aetna's Letter to Providers
02.07.08 Update on Preventive Medicine Reimbursement Policy by UnitedHealthcare:
Claim adjustments to be retroactive to August 27, 2007
UnitedHealthcare is pleased to announce that revisions to its Preventive Medicine Reimbursement Policy are now in effect. As revised, the policy allows for separate reimbursement for preventive medicine services and acute care Evaluation and Management (E&M) services on the same date of service.
The claim system enhancement needed to implement the new policy occurred on December 8, 2007. The updated policy is available in the Reimbursement Policies section of Unitedhealthcareonline.com. Because of the unanticipated delays in the policy’s formal effective date, UnitedHealthcare will, as an accommodation to physicians, retroactively apply the new policy to claims with dates of service of August 27, 2007 or later.
UnitedHealthcare is currently identifying and adjusting claims that were processed prior to the new policy becoming effective that had service dates between August 27, 2007, and December 8, 2007. Therefore, physicians do not need to seek adjustments of these claims.
Link to UnitedHealthcare's Web site
02.01.08 Important Announcement On Continuation of Epocrates Agreement by UnitedHealthcare
UnitedHealthcare's senior leadership has decided to extend its agreement with Epocrates to host prescription drug lists on physicians' handheld devices. As previously communicated, the agreement was set to expire on February 1. UnitedHealthcare will work directly with Epocrates on behalf of all UnitedHealth Group companies to draft an enterprise agreement. Physicians and businesses should have no interruption in their PDL hosting service from Epocrates.