Managed Care

On April 26, 2006, the Texas Pediatric Society Pediatric Council met with the leadership of BlueCross BlueShield of Texas (BCBSTX).  The Pediatric Council gave Texas Pediatric Society members the opportunity to contribute items to include on our agenda.  Click here to read about our discussion with BlueCross BlueShield of Texas.

The TPS Pediatric Council has scheduled a meeting with the leadership of CIGNA Healthcare.  Check back regularly for the results of that meeting! 


Influenza Resource Page Now Available

A brand new Influenza Resource Page for health care professionals, developed by the AAP Committee on Infectious Diseases, is now online.  This comprehensive list of influenza resources is designed to serve as a centralized point of reference for vaccine, prevention, treatment, reimbursement, policies, news, and other information pertaining to seasonal, avian, and pandemic influenza and will be updated periodically with new information and links as necessary.  These resources can be used for members in dealing with carrier coverage issues.

Seton and Austin Regional Clinic Create Area Health Plan

Two of Central Texas’ largest health care providers are creating a "self-contained" preferred provider network for a new health insurance plan for Central Texas employers. Austin Regional Clinic, PA and the Seton Healthcare Network, together comprising more than 750 physicians and 10 hospitals throughout Central Texas, are joining to form a preferred provider network for a new health insurance plan called Healthy Equations set to go live July 1.  Read more about Health Equations here.

Oxford Bundling Vision Screens with Preventive Medicine Services

Oxford is adopting the same policy stance as UnitedHealthcare, who now owns Oxford, in that it does not pay separately for vision screening (CPT code 99173).  The American Academy of Pediatrics has had ongoing dialogue with UnitedHealthcare about its policy of bundling vision screening with preventive medicine visits.  Click here for an appeal letter about bundling vision screens

Like many other payers, Oxford uses RBRVS in determining payment.  Since CPT code 99173 does not have any RVUs on the Medicare physician fee schedule (ie, 0.00) there is no way to calculate payment for this service at the present time.  The AAP Committee on Coding and Nomenclature (COCN) is working hard to get the RUC-approved RVU for code 99173 published on the Medicare physician fee schedule, possibly in time for 2007 RBRVS.  Dr. Dick Justman, UHC National Medical Director has indicated that UHC would likely follow CMS policy if CMS publishes an instruction that vision screening should be reimbursed separately.  In the interim, it remains a contractual issue, and pediatricians should review their individual contracts regarding provisions for billing families and referrals to specialists.

Oxford is not a defendant in the multidistrict litigation and UHC has not yet agreed to a settlement, therefore, there is not a process to file a compliance dispute with either Oxford or UHC.  There is a process to file compliance and billing disputes with Aetna, Cigna, HealthNet, Humana, and Anthem/Wellpoint.  (See for additional details.)  The trial date for those carriers who have not settled is set for September 18, 2006. 

UHC Changes Policy on Preventive Services and Modifier -25

In its May 2006 Bulletin(see pg. 5) UHC announced it will change its Preventive Medicine and Screening Policy and will begin to pay for both the preventive medicine service and problem-oriented E/M service provided to the same patient on the same day.  By late 2006, UHC will pay the preventive medicine code at 100% of the allowed rate and the E/M code at 50% of the allowed rate.  Until now, UHC would pay for only one of the reported services (either the preventive care or the E/M service).  Although UHC will only pay 50% of the allowed rate for E/M code, this represents a significant shift in the carrier's policy and follows Aetna's policy change to pay separately for both a preventive care and E/M service when reported for the same patient on the same day of service.

Aetna Changes its Policy on Modifier -25

Aetna and several state medical societies have been in mediation over payment of claims appended with Modifier 25 and an agreement was reached resulting in Aetna paying separately for specific procedures billed with an Evaluation and Management (E&M) code appended with Modifier 25.  Previously denied claims with dates of service from July 1, 2004 for specific procedures (including CPT code 99173 {vision screening} and 96110 {developmental screening}) billed with an E&M code appended with Modifier 25.  Claims submitted without a modifier originally should not be resubmitted.  Aetna will pay the specific procedures listed on its website if they are billed with an E&M code appended with a modifier.  Additional information including the list of CPT codes can be accessed on the Aetna website.

AMA Offers Model Managed Care Contract

Unfair managed care contracts continue to be the source of many complaints and problems physicians have with health insurers and payers.  The American Medical Association's Private Sector Advocacy unit has updated the AMA Model Managed Care Contract to reflect legal and other developments in the marketplace since 2002, including developments in the area of external review, "all products" provisions, credentialing, and fee-for-service arrangements.  Download the Model Contract here

HMO RICO Settlements

In 2000, individual physicians and medical societies filed lawsuits charging the nation's largest health plans with bundling, downcoding and arbitrarily denying claims to reduce what was paid.  The lawsuits were combined and given class-action status. More than 900,000 physicians are considered to be part of the class.

As of January 2006, Aetna, CIGNA, HealthNet, Prudential, Anthem/WellPoint and Humana have reached agreements with the plaintiffs' attorneys that were approved by U.S. District Court Judge Federico Moreno in the Southern District of Florida.  He is still overseeing similar class-action lawsuits against the remaining defendants: Coventry Health Care Inc., PacifiCare Health Systems, and United Healthcare Inc.  The trial date for the remaining lawsuits has been moved from April 17, 2006 to September 18, 2006.

Since the settlements began, insurers have emphasized that their companies are working to simplify and improve transparency in their claims-payment process, as well as paying physicians faster and with greater accuracy.  The settlement terms are intended to help streamline communication between physicians and the companies, reduce administrative complexity in the claims payment system and fix coding issues such as bundling, downcoding, recoding, etc. and to help improve the quality of the health care delivery system.

For information about each of the settlements and related documents, click here.

For additional information about practice management, please contact:
Laura Blanke, MPH, Practice Education Manager
401 West 15th Street, Suite 682
Austin, Texas 78701
(512) 370-1509

Disclaimer: This information is available to provide general education.  It is provided with the understanding that Texas Pediatric Society is not engaged in rendering legal, medical, or other professional services.  Although prepared by professionals, the information provided on this web site should not be utilized as a substitute for professional services.