Latest On Humana Downcoding Controversy
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Hi, everyone.
Here's an update from the Orlando Business Journal on the continuing saga of Humana vs Florida physicians on the issue of (wholesale) downcoding. It has implications for providers across the nation.
Sorry this is a few days late -- my e-mail program has been acting-up.
Gil Weber
Humana, doctors strike billing deal
Reviews of some Florida doctors' claims will be shelved.
Monday, March 6, 2000
Susan Lundine, Senior Staff Writer, Orlando Business Journal
TALLAHASSEE -- After four months of back and forth, the Florida Medical Association and Humana Inc. have reached an agreement on how to handle the insurer's controversial practice of downcoding.
Under fire nationwide, downcoding involves paying doctors a fee for a brief or uncomplicated visit -- even though the visit may have involved extensive time and attention.
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.
As previously reported in Orlando Business Journal, Humana officials agreed late last year to make some concessions. Among them: Stop the practice of automatically challenging all doctors' bills reflecting the most complicated office visits.
Humana instead agreed to focus on 5,000 doctors nationwide who, according to the insurer, file more complex medical claims than their peers.
However, the national list included 1,500 Florida doctors. The powerful 17,000-member Florida Medical Association threatened to sue if the insurer didn't give even more ground.
The two groups have been in discussions ever since.
Now, the physicians' trade group says the two have reached an accord:
Humana has agreed to provide the 1,500 Florida doctors whose bills are now targeted for automatic review with a detailed explanation of what they can do to get off the list. Humana also will designate a person to help physicians do so.
The insurer and the medical association jointly will conduct free educational seminars for doctors and their office staff on how to submit claims.
An expedited resolution process will be put into place for doctors to handle any problems with downcoding.
If Humana needs additional documentation, doctors will have 35 days to submit information proving their claim is valid.
Doctors will receive a letter clarifying steps they and their office staff need to take to submit medical claims.
Follow-up meetings between the FMA and Humana will be held to assess the effectiveness of the agreement.
"We're having an ongoing dialog with Humana on a daily basis," says John Ridge, the physician association's director of managed care and medical economics. "We will sit down sometime in the next 60 days to assess the impact of the agreement."
No matter how successful the agreement is, Florida Medical Association President Dr. Mathis L. Becker stresses that this is not a comprehensive solution to problems with managed care. In fact, he characterizes the agreement as merely "a first step."
Joe Berding, Humana's regional vice president, agrees that there are more issues that need to be ironed out.
For example, Berding would like to see more doctors file their medical claims electronically, and he'd like to see contracts between doctors and managed care companies simplified.
But both men say the agreement over downcoding is a positive sign. Becker says he's glad Humana was willing to resolve the issue without litigation. Adds Berding, "If it results in more accurate coding, it resolves problems for all of us.
"Now that we've worked out one issue, let's get started on the rest of them."
However, Peter Young, a Fort Myers health care consultant, is more skeptical.
"All these practices that have doctors screaming are efforts to control costs," says Young. "Humana is telling the investment world that it must control costs and utilization, but that will be difficult to do when entering agreements like this."
On the other hand, Young says he doesn't see the agreement between the medical association and Humana "having a silver lining for the doctors."
That's because not all doctors do practice the most cost-effective type of medicine possible, he says.
"And the financial pressure that managed care companies are under continues to put pressure on whoever provides the health care services -- including the doctors," says Young.
FMA officials, though, are taking a wait-and-see attitude.
Says Ridge, "We hope it has a real positive impact for physicians -- but if it doesn't, we are willing to go back to the table to seek legislation or legal remedies."
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