More On HMO Downcoding
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Hi, everyone.
Just wanted you to have this story from the Orlando Business Journal. More information on the continuing battle in Florida over HMO downcoding.
Gil Weber
Doctors propose revisions to Humana's payment process
Monday, November 22, 1999
Susan Lundine, Staff Writer, Orlando Business Journal
TALLAHASSEE -- Officials at the Florida Medical Association want Humana Inc. to make even more revisions to its controversial payment method, known as downcoding.
Under fire nationwide, downcoding involves paying doctors a fee for a brief or uncomplicated office visit -- even though the visit involved a lot of time.
As previously reported in the Orlando Business Journal, Humana officials agreed to make some concessions after being blasted by doctors for its payment process. Florida doctors, however, said that Humana didn't go far enough, and threatened to sue if more changes weren't made.
Now, the powerful 17,000-member Florida Medical Association has some proposed changes to the insurer's payment process.
In the Nov. 10 letter, FMA President Dr. Mathis L. Becker suggests whenever Humana decides to further investigate a medical bill submitted by a doctor:
That a notification letter and request for more information be sent immediately to the doctor.
That an interim payment be sent to the doctor while the medical bill is undergoing review.
That Humana's 14-day response period, during which time doctors are instructed to send more information to justify the medical bill, be increased to 35 days to comply with Florida law.
In addition, when Humana asks the doctors for more information regarding a particular medical bill, the FMA feels that letter should clearly outline the steps physicians must follow to receive a fair and prompt payment.
Other revisions the FMA wants to see: The notification letter also should inform the doctors who are having all of their medical bills reviewed by Humana that they may submit the additional requested information to Humana, as well as to its claims processing company, Aztec Medical Systems, via fax or e-mail.
In addition, doctors should be told what they have to do to get off the list of physicians whose medical bills are under 100 percent review by Humana. The FMA also wants Humana to clearly state if it plans to provide coding educational sessions to doctors and their staffs.
Financial woes caused issue?
Health industry experts say insurers, which are losing record amounts of money, are turning to tactics such as downcoding to wring out savings.
Insurers, however, say the purpose of the practice is simply to make sure they are not overpaying doctors.
In July, Humana sent 90,000 letters to doctors in Florida, Texas and Kentucky challenging bills that charged the two highest levels of a five-level office visit fee scale. A month later, the insurer expanded its downcoding practice nationwide.
After feeling the ire of doctors, however, Humana agreed last month to stop reviewing all the more complex medical claims filed by all its doctors.
Instead, Humana decided to focus on 5,000 doctors nationwide who, the insurer says, file more complex medical claims than normal.
Other concessions the insurer made last month: Humana offered to teach doctors how to put the proper code on each medical claim they file. The insurer agreed to set up a task force to improve the medical claims review process and help define what constitutes filing too many complex medical claims.
But the Florida Medical Association contends that Humana's proposed plan isn't good enough, because the downcoding still will impact 3,000 Florida doctors. The organization may file a lawsuit against Humana, claiming that the insurer's downcoding practices are illegal.
Humana officials could not be reached for comment, and John Ridge, the FMA's director of managed care and medical economics, says he hasn't gotten a response to the Nov. 10 letter yet from Humana.
However, he remains hopeful.
Says Ridge, "I think we can work things out. I think it's very positive that Humana is willing to discuss the issues."
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