10.30.07
Posted in Brain Injury News at 1:55 pm by Last
Dr. Marilyn Kraus of the University of Illinois at Chicago College of Medicine recently reported a new study that states diffusion tensor imaging can detect changes in the brain that correlate to cognitive deficits in those with mild traumatic brain injury.
In the study, 37 traumatic brain injury patients -- 20 mild and 17 moderate-to-severe -- and 18 healthy volunteers underwent diffusion tensor imaging and neuropsychological testing to evaluate memory, attention and executive function. The researchers found that structural changes in the white matter correlate to observable cognitive deficits related to thinking, memory and attention.
You can read more on Dr. Kraus' study here.
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Posted in Brain Injury News at 1:55 pm by Last
Dr. Marilyn Kraus of the University of Illinois at Chicago College of Medicine recently reported a new study that states diffusion tensor imaging can detect changes in the brain that correlate to cognitive deficits in those with mild traumatic brain injury.
In the study, 37 traumatic brain injury patients -- 20 mild and 17 moderate-to-severe -- and 18 healthy volunteers underwent diffusion tensor imaging and neuropsychological testing to evaluate memory, attention and executive function. The researchers found that structural changes in the white matter correlate to observable cognitive deficits related to thinking, memory and attention.
You can read more on Dr. Kraus' study here.
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10.29.07
Posted in Uncategorized at 9:34 pm by Last
Like all physicians, orthopedic surgeon Frank B. Kelly, MD, depends on steady cash flow to keep his office running. But Dr. Kelly, who directs the seven-doctor Forsyth Street Ambulatory Surgery Center in Macon, Ga., finds himself constantly battling private insurance companies to get payment for patient claims.
Even though Georgia law requires reimbursement within 15 days, Dr. Kelly says payment can take as long as six months. His financial situation gets so bad that he sometimes delays purchasing new equipment and sweats the months liability premiums come due. "You don't make plans for capital expenditures unless you have the money in hand," he says. "You cannot depend on being paid by an insurance company."
By 2007, all 50 states had some form of law penalizing health insurers for late payments. Yet the problem persists, physicians say.
Insurers have found loopholes to get around the deadlines and are using federal law to slip out of state laws, doctors say.
Rep. Charles B. Gonzalez (D, Texas) was so upset by reports of delayed payment from physicians in his San Antonio district that he held an August hearing on the issue.
"Would they accept the same timeline for payment of premiums as they would of claims?" asked Gonzalez, who chairs the House Small Business Committee's panel on regulation, health care and trade. "They don't carry you for three, four, six months. You'd probably get canceled."
What is needed, says the American Medical Association, is a tough federal law penalizing insurance companies that delay payment.
Market dominance a factor
One reason insurers can ignore prompt-payment laws is that they dominate the market in most communities, says Cecil B. Wilson, MD, immediate past chair of the AMA Board of Trustees. It gives them tremendous negotiating power and prevents physicians from addressing unfair payment practices. The situation, called an oligopsony, occurs when only a few buyers operate in a market with many sellers.
AMA's 2007 update to "Competition in Health Insurance: A Comprehensive Study of U.S. Markets" found that in 299 of 313 metropolitan statistical areas a single insurance company commanded at least 30% of the market. One insurer had 70% or more of the market in 74 areas, while in 15 areas a company had at least 90%.
| 55% of U.S. employees work for companies that self insure, making the plans exempt from state insurance laws. |
The U.S. Justice Dept. has placed conditions on only two of 400 approved mergers in the health insurance industry in the past 10 years, according to the AMA report. The physician community has fought back against insurers' practices.
State medical societies and individual physicians brought lawsuits against 10 companies. The cases were consolidated and filed as a single class-action lawsuit in 2000. The action, In Re: Managed Care, claimed that the plans unfairly denied or delayed physician payments. The resulting settlements by seven companies amounted to more than $1.53 billion, about $384 million of which was direct payments to physicians. About $1.1 billion in savings for doctors is expected to be generated by changed business practices agreed to by insurers. The remainder goes toward compliance and enforcement and to two foundations to improve health care quality.
But the settlements eventually will expire, Dr. Wilson said, and there are no guarantees that the companies will stick to the terms of the agreements. The Cigna settlement expired Sept. 4.
Physician complaints about delayed payment also resulted in state legislatures taking action in recent years. Some states, such as Alaska, Idaho, Rhode Island and West Virginia, enacted their first prompt-payment laws. Others shortened the time for paying claims under existing laws. New Jersey, for example, trimmed the deadline from 60 days to 30 days for electronic claims. Some states, such as Alabama, passed laws defining clean claims.
States have imposed at least $76 million in fines in the past 10 years against insurance companies for failure to comply with prompt-pay laws, according to the AMA.
Improved performance claimed
Insurers, however, say they are improving their performance. Aetna offers online submission of claims so physicians can receive payment more quickly than with paper claims, said spokeswoman Roni Grossman. In turn, the company does not have to spend as much time handling paper claims, further speeding the claims process, she said. Humana pays 90% of its claims within 14 days, said company spokesman Jeffrey Blunt.
Cigna HealthCare has improved its record enough to become the top-rated insurer overall by Athenahealth Inc., a company that provides physician billing, practice management and electronic medical record services, said Cigna spokesman Joe Mondy. The insurer placed third in terms of payment speed. The company boosted the accuracy of its payments and expanded its ability to receive claims electronically, Mondy said.
| States have fined insurers $76 million in the past 10 years for violating prompt-pay laws. |
Athenahealth's PayerView survey shows that insurance companies in general are getting better at paying claims in a timely way. Average days in accounts receivable among national insurers decreased from 36.2 days in 2005 to 34.4 days in 2006, found the survey of 8,500 physicians and medical professionals.
Yet that still exceeds the time limits of many state laws. At least 21 states require that paper and electronic claims be paid within 30 days, according to 2006 data from HealthPro Consulting Inc., a New York-based firm that offers reimbursement and coding services to physicians. Only one state -- South Carolina with its limit of 60 days for all claims -- allows insurers to go beyond 45 days to pay a claim, HealthPro found.
Regional insurers are more likely to have slower payment than national companies. For example, 2006 Athenahealth data show that 11 private regional plans had claims in accounts receivable more than 45 days on average.
Physicians charge that one of the most common practices leading to long lag times is insurers' refusal to pay claims they say aren't "clean." They also ask patients to send unnecessary information before they'll pay, doctors alleged.
For example, Dr. Kelly said, an insurance company denied a claim for procedures performed on both of a patient's knees during one office visit, arguing that the claims were duplicative. Insurers also have asked his patients to provide accident information, even though it's already provided on a claim form, or information about pre-existing conditions. Health plans often won't send a copy of the request, so Dr. Kelly's staff can't help patients get the information. His office administrator, Melissa Zediker, relates the example of a claim for hand surgery. It included the surgeon's name and license number, but the insurer denied payment because the claim didn't state the doctor's degree.
"Most of it is really ridiculous -- standard form letters in their system that they shoot off and hope the provider doesn't address," she explained. "A lot of these claims get paid down the road, but they hold the funds 30 to 90 days longer than if it went through with a 'clean' claim," she said.
Doctors say another problem is that many health plans are not subject to state prompt-pay laws. The federal Employee Retirement Income Security Act exempts companies that self-insure from state insurance laws. About 55% of workers have such coverage, according to the 2007 Kaiser Family Foundation Employee Health Benefits Survey. The percentage rises with firm size: 77% of workers at businesses employing more than 200 people are in self-insured plans.
"There's really no effective mechanism for overseeing self-insured health plans except through the [U.S.] Dept. of Labor," explained National Assn. of Insurance Commissioners President-elect and Kansas Insurance Commissioner Sandy Praeger. As of now, though, there is no federal prompt-pay law for the Labor Dept. to enforce.
Federal action
A federal law would fill the loopholes, explained the AMA's Dr. Wilson. He outlined the elements of a proposal when testifying to the House Small Business Committee's health panel in August:
- A strong federal standard. The AMA's policy is to support legislation that requires payment within 30 days for clean paper claims and 14 days for clean electronic claims.
- Stiffer fines than those in state laws to deter bad behavior. Interest should be assessed on the amount of payment outstanding and increase with the claim's delinquency. Physicians' attorney's fees and costs also should be provided when they win a claims dispute with an insurer.
- State law protections. Stronger state laws should be protected, and state requirements not covered by a federal standard should not be preempted.
- Application of state laws. Any federal law should clarify that state prompt-payment laws apply to all nongovernment health plans, denying insurers the argument that ERISA preempts state law.
- Time limits for notification. Federal law should set a statutorily defined time limit for insurers to notify physicians that additional information is needed to process a claim. The notice should specify all problems with the claim and give an opportunity to provide the information needed. Insurers also should be required to pay any portion of a claim that is complete and uncontested.
Federal action would be a "wake-up call" to insurance companies, Rep. Gonzalez said. "You would have companies who would definitely know it has gotten Congress' attention."
Praeger cautioned against Congress approving a complicated law. Lawmakers should relax ERISA's state preemption in regard to prompt payment, she said.
Will Congress pass a prompt-pay bill in the near future? There is definitely interest, Gonzalez said. "I think we would have tremendous support. It's just a matter of getting people organized." He does not intend to introduce a prompt-pay measure for consideration on its own. Instead, he will build a consensus for legislation and look for a bill to attach it to in an effort to get it passed in the busy last few months of this year.
The AMA will continue working with Congress to pass a bill, Dr. Wilson said. The Association will investigate and publicize insurance company practices so state insurance commissioners can enforce existing laws, he added.
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Posted in Uncategorized at 9:34 pm by Last
Washington -- Physician organizations expressed dismay and vowed to press forward after the House on Oct. 18 failed to override President Bush's veto of a children's health care bill.
The American Medical Association will continue to work with lawmakers from both sides of the aisle to pass legislation reauthorizing the State Children's Health Insurance Program, said Board of Trustees Chair Edward L. Langston, MD.
"The number of uninsured kids has increased by nearly 1 million over the past two years, and action must be taken to reverse this growing trend," he said. SCHIP expired Sept. 30, but Congress extended funding until Nov. 16.
The American College of Physicians is urging lawmakers to pass another bill with levels of funding and coverage comparable to the vetoed version. "The current SCHIP formula clearly does not go far enough," said David C. Dale, MD, the college's president. "Until SCHIP is reauthorized, millions of children will be at risk of being denied basic health care needs."
But both parties are reluctant to change their opposing stances on program funding and eligibility.
Democratic leaders' strategy is to amend the bill slightly to attract the Republican votes needed to achieve a veto-proof majority.
House Speaker Nancy Pelosi (D, Calif.) and other Democrats said they would not support a measure that covers fewer children than the five-year, $60 billion Children's Health Insurance Program Reauthorization Act of 2007 would have covered. Bush vetoed the bill on Oct. 3.
"The president and his allies in Congress may have stopped the SCHIP bill today, but we still will not allow that to deter us from our goal, which is to insure 10 million children in America," Pelosi said. SCHIP covers about 6 million children and 600,000 adults.
Majority Whip Jim Clyburn (D, S.C.) said it's a moral imperative to cover the children of America's working families. "Make no mistake, the president will see this legislation on his desk again in short order."
The House fell 13 votes short of the two-thirds majority needed to override the veto. Despite the shortfall, Democrats claimed victory because they were 11 votes closer to a veto-proof majority than they were when the House passed the bill 265-159 on Sept. 25. The Senate passed the measure with enough votes to override a veto on Sept. 27.
Minority Leader John Boehner (R, Ohio), who -- with other Republicans -- predicted that the veto override would fail, wrote a letter to Pelosi on Oct. 19 requesting meetings to craft a more bipartisan SCHIP measure. None of the 151 Republicans who voted against the SCHIP bill on Sept. 25 supported the veto override, despite an extensive public campaign by bill supporters. "Republicans want to renew SCHIP, as do Democrats here in this chamber, yet there has been no opportunity to work together," Boehner said.
On Oct. 18, House and Senate Republicans introduced their SCHIP bill, the More Children, More Choices Act. The measure's sponsors said it also would cover 10 million children with the help of $1,400-per-child tax credits. The bill's text was not available at press time.
Pelosi said she opposes using tax credits to increase SCHIP funding. The Democrats' bill called for a 61-cent increase in the federal cigarette tax, which is 39 cents. Bush and many Republicans are against raising the tax.
If the Democrats can't get enough votes and decide not to negotiate a new bill with Republicans, they could try to pass a one-year program reauthorization. The idea would be to extend the program beyond the November 2008 elections, with the hope that a president more open to the Democrats' vision will be voted into office.
Jim King, MD, president of the American Academy of Family Physicians, said he was disappointed that the override failed but that a drawn-out battle over SCHIP wasn't appealing. It's time for full reauthorization, he said. "I'm hoping that [Democrats have] got their point, they've got their political capital from this vote, and now they'll go back and both parties will arrive at something that's positive for the citizens of this country."
Adopting a short-term funding resolution could be the "worst possible outcome for states," said Martha A. Roherty, director of the National Assn. of State Medicaid Directors. That's because it would make it more difficult for states to sign contracts with private health plans that provide the benefits and would make program administration more difficult. It also would limit states' ability to start any expansions or innovations.
Republicans: Focus on low-income kids
The Democrats' bill would limit SCHIP eligibility to enrollees earning 300% of poverty or less, transition adults to Medicaid, restrict coverage of parents, and bar immigrants, legal or otherwise, from the program.
Republicans, however, remain opposed to the Democrats' eligibility provisions. They said even limiting the program to children from families at or below 300% of poverty (about $62,000 a year for a family of four) would cause SCHIP to siphon off enrollees from private insurance plans, an effect known as crowd out.
Rep. Steve King (R, Iowa) said the measure represents excessive government intrusion into the private health system. "This is the cornerstone of socialized medicine."
Jay Berkelhamer, MD, president of the American Academy of Pediatrics, said those who spoke against SCHIP should know that the program already is focused on low-income children. Ninety-nine percent of SCHIP enrollees are in families earning 300% or poverty or less, and 91% are from families earning 200% of poverty or less, said an October analysis by the Center for Children and Families at Georgetown University.
The Democratic bill eventually would allow eligibility expansions beyond 300% of poverty if a state's percentage of low-income children with health coverage reached the average percentage of the top 10 states.
Republicans would like tighter eligibility. Many, including President Bush, want guarantees that SCHIP will cover 95% of children in families earning 200% of poverty or less before allowing an eligibility increase to 250% of poverty. No state has enrolled more than 92% of children in families earning 200% or less of poverty.
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Posted in Uncategorized at 9:34 pm by Last
Washington physicians and insurers are working against a new law regarding "bad-faith" handling of insurance claims.
On the Nov. 6 ballot, Referendum 67 will ask voters to reject or approve the statute. The law allows policyholders to sue their insurance companies for up to triple damages, plus legal fees, when insurers unreasonably turn down their claims. A state court would decide whether the claims denial was unreasonable and whether triple damages were warranted.
The law is on hold pending the referendum's outcome.
Washington does not allow punitive damage awards. Although the new law, called the Insurance Fair Conduct Act, does not define its penalties as punitive damages, they are the equivalent, legal and policy experts said.
The act, signed by Gov. Chris Gregoire in May, would apply to most types of insurance, except health plans. It remains unclear whether the law would directly impact medical liability carriers.
The confusion arises because physicians are policyholders of medical liability insurance. However, medical liability claims are triggered by a legal complaint by, or on behalf of, a patient -- a third party. The question, then, is whether a patient or a patient's attorney can sue a physician's medical liability insurer for allegedly failing to properly cover the doctor's claim.
Also unclear is whether a physician, as a medical liability insurance policyholder, could sue his or her insurer for settling or defending a case in bad faith, or refusing to take on the doctor's claim altogether.
Trial lawyers and other supporters of the law said it's a way to hold insurance companies responsible for doing good business.
But physicians, insurers and some consumer advocacy groups worry the law would lead to a broader application of punitive damages. Ultimately, this would result in higher medical liability insurance premiums for doctors and possibly higher health insurance premiums for patients if health plans are targeted in the future.
"All it does is increase the incentive for trial attorneys to fish for cases that may not have merit," said Washington State Medical Assn. Executive Director and CEO Thomas J. Curry.
Though the current statute excludes health plans and might not directly impact medical liability carriers, they are likely next in line, he said. The original draft of the bill allowed third-party claims and applied to health plans. State consumer-protection laws already give doctors and patients the right to sue insurers for wrongfully denying them coverage, so the law is excessive, Curry said. The state's insurance department also can fine carriers, he added.
Gary Morse, general counsel to Physicians Insurance A Mutual Co., the state's largest medical liability carrier, said Washington's law has a lower threshold for proving misconduct. Whereas states that permit punitive awards typically require proof of bad intent, Washington's standard would be reasonableness, he said.
"This bill creates the potential for treble damages for mere negligence, and that's very bad public policy anywhere," Morse said. "Once you have a foot in the door, what's to prevent punitive damages in treating a patient?" he warned.
A study of five other states with similar laws by the actuarial firm Milliman Inc. and a report by Washington's Office of Financial Management, both suggest that such bad-faith insurance measures generally increase lawsuit filings and insurance premiums. Insurers could be forced to settle claims just to avoid the threat, the Milliman study stated.
"You have guaranteed mandatory attorney's fees, triple damages and the lowest legal threshold in the nation -- it's a perfect storm," said Dana Childers, executive director of the Washington Liability Reform Coalition, which supports tort reform. She also is a spokeswoman for Consumers Against Higher Insurance Rates, a campaign to overturn the new state law.
This year, at least eight other states pursued similar measures, some of which include medical liability carriers and health plans, according to research by the Property Casualty Insurers Assn. of America. At press time in late October, the status of those efforts was unclear.
Another view
On the other hand, trial lawyers and the consumer advocates who approve of the law say it would simply encourage insurers to treat doctors and patients fairly. As long as they did so, insurance premiums would not be affected, said Sue Evans, spokeswoman for Approve 67, a campaign to uphold the measure. She said previous state insurance laws don't go far enough because they require carriers to pay only the value of the denied claim, without additional consequences.
"It actually pays to delay [claims] and gives [insurers] incentive to drag policyholders into the court system," where legal fees come out of consumers' pockets, Evans said. "The difference [under the new law] is if there is bad faith, there will be consequences."
Larry Shannon, government affairs director for the Washington State Trial Lawyers Assn., noted it would be up to a judge to decide if triple damages were warranted. He believes the law would apply to medical liability carriers, though in rare circumstances. The new act would serve as a reminder to insurers that they have an obligation to properly communicate with physicians about the scope of their policy coverage and "provide him or her with the security of knowing the insurance has to be there," Shannon said.
But it also could help with continuity of care for patients injured in auto crashes and ensure payments to doctors for treatment they provide.
Evans said there are no plans to expand the statute into other areas.
Jonathan Seib, a policy adviser in Gregoire's office, said the governor will vote "yes" on the referendum to keep the law on the books. If needed, she'll provide further clarification on its application.
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