AmeriGroup backs out; May 24

AmeriGroup backs out of Wellness Plan deal
By PAUL NATINSKY
Managing Editor
After agreeing to buy the troubled Wellness Plan HMO, AmeriGroup terminated its offer early this month leaving uncertain the disposition of more than 100,000 Medicaid patients.

After agreeing to buy the embattled managed care plan, the Virginia Beach, VA-based corporation withdrew its offer apparently over a dispute about payment rates. The company offered no comment, but Michigan Insurance Commissioner Linda Watters did.

“They knew the proposed rates, agreed to move forward with the deal and then attempted to renegotiate rates,” stated Watters. “When they were rebuffed, AmeriGroup terminated the letter of intent. Not only has their conduct resulted in unnecessary disruption, but also has wasted valuable time and resources that could have been better spent pursuing serious offers.”

The debacle comes at a particularly sensitive time as bids for Medicaid managed care contracts were due May 17. MSMS Legal Counsel Patrick Haddad of Kerr, Russell, Weber said bidding on the Medicaid contract is a condition of sale for purchasing both the Wellness Plan and another Detroit-area Medicaid HMO, OmniCare.
Haddad said it wouldn’t make sense for a company to bid on the plans without the intention of keeping the plans’ Medicaid business. He said assets of the plans that are for sale are limited to the HMO license and member enrollment (patients).

In a related development, a deal by Coventry Health Care to buy OmniCare was met with judicial approval, said Haddad. He said an important part of the deal for physicians is an allowance for physicians who no longer wish to participate in the plan to terminate their membership in April 2005 rather than at the end of the state’s fiscal year in September.

The Wellness Plan deal was for an estimated $38 million, the OmniCare deal $12.6 million. The HMOs have a combined enrollment of more than 150,000.

OmniCare and the Wellness Plan are under state rehabilitation, the insurance-industry equivalent to bankruptcy with the intent of reorganizing. The plans have been under that status since 2002 and 2003 respectively.

The new bidding procedure features rates determined by a federally sanctioned process and enhanced reserve cash requirements to ensure financial stability of all Medicaid managed care plans.

OBITUARY
Agnes Borchak
Agnes Borchak, wife of WCMS Past President Robert Borchak, MD, passed away April 2, 2004 at age 77.

She loved music and played several musical instruments. As a matter of fact, her love of music led her to the love of her life.
She played the piano, the organ and the clarinet. When she was a student at the University of Detroit, she played the clarinet in the marching band.

“That was one of her better endeavors because that’s where she met me,” Dr. Borchak told the Detroit Free Press. “She needed a drawing tool, and I came up with a scrap of a pencil. She was at a loss to copy what the band leader had up on the board, and I responded in a timely way.

“I’d been keeping my eye on her for a while, and that was the beginning of a 57-year relationship.”

Besides her husband, survivors include four sons, Robert, Paul, Michael and James; two daughters, Deborah Crick and Denise Gornick; a brother; four sisters and 12 grandchildren.

Many generous people contributed to the WCMS Foundation Memorial Fund in her name. Contributions may be sent to the Foundation at 3031 W. Grand Blvd., #645, Detroit, MI 48202.

Contributors to the WCMS Foundation Memorial Fund
in the name of Agnes Borchak
Wayne County Medical Society
Adam & Linda Jablonowski
The Sociable Scoundrels
Howard & Mary Sherrill
Carmen Foote
Dr. Henry & Mrs.Domzalski
Charles & Virginia Riddle
Michael Sandler
Fred & Susan Schwartz
Arthur & Eleanor Berendt
Richard & Dorothy Deisler
Grosse Pointe Community Chorus
Kim Khong Lie, MD & Mado Olga Lie
Jane & Matthew DeLorenzo
Roberta & Jim Hoekwater
Jack & Helena Paczala
Cynthia Bimberg
Grosse Pointe Surgical Associates
Paul & Donna Cusac
Sharon Reider Paliti & Dave Foster
Irene & Kenneth Willmarth
Del Kubicki
Peter  & Lois Duhamel
George P. Kypros, MD
Joan Thomas & Theodore Shandor

Executive Council Meeting Notes:
Health authority needs city, county support
By EDWARD JANKOWSKI, MD
WCMS President
Detroit/Wayne County Health Authority
The Authority continues to be stalled by the inaction of the City Council and the Wayne County Commission. It is now anticipated that the two groups will not consider approving (or disapproving) the Interlocal agreement until the end of May at the earliest. On behalf of the Society, I have sent a letter to all Council and Commission members, urging them to act as quickly as possible. Substantial federal, state and foundation dollars are now available to get the Authority started. Further delay could jeopardize this funding. Additionally, there is the continuing issue of the DMC operating at a loss and the impact the health authority could have on its financial well being. A letter from MDCH Director Janet Olszewski responds to issues I raised in a letter to the governor.

Antietam Building
We expect to close on the sale of the building by the end of May. Our attorney and the WSU attorney are preparing the legal document to consummate the sale of the land and the building.

Meet 'N' Greet
On March 25, 2004, 6 p.m., at Fishbone's in Greektown many of our WCMS leaders met with Detroit and Wayne County representatives and senators in a social environment to exchange ideas on the state of medical practice and the legislative issues of interest to our members. This meeting sponsored by MSMS and our Legislative Committee always draws a good crowd and this year it was enhanced through the participation of many osteopathic physicians.

The AMA National Advocacy Conference was held in Washington March 28-30. Rick Smith and I represented Wayne County. Several WCMS members were there representing MSMS. The meeting concentrated on liability reform and getting a permanent fix in the Medicare formula for reimbursement of physicians. I have discussed more of the meeting in a recent DMN report and we also have run the tops six issues that AMA is working on currently in Washington.

Blue Cross-Shield Reform
More than 50 physicians, office managers and billers attended the combined WCMS/MSMS meeting on Wednesday, April 21. MSMS legal counsel Dan Schulte and Bill Horton, legal counsel for the Oakland County OB/GYN group discussed the federal lawsuit against the Blues. Dr. Mike Sandler and Rep. Dave Robertson reviewed the MSMS activities with the Blues and the introduction of reform legislation. A further report will be available at Executive Council describing a recent meeting between MSMS/WCMS leaders and Blue Cross-Blue Shield executives.

Medical-Legal-Business Seminar was held at the WSU School of Medicine on April 24, 2004. More than 40 students showed up early Saturday morning to hear the bad news about the legal issues facing physicians. Three attorneys form our Medical Legal Committee did an excellent job presenting the problems that physicians face on a day-to-day basis. In addition, Drs. Boccaccio, co-chair of the Committee and Dan Michael and myself tried to put a better face on what students should expect when they enter practice, either solo or in a group. The participants seemed to be enthusiastic about the information transmitted by us and the Committee plans to continue these seminars in the fall.

We had about 20 doctors and staff at a meeting with US Sen. Debbie Stabenow April 26, 2004 to discuss federal legislative issues. As we expected, not much legislation is likely to be enacted during this presidential election year. Sen. Stabenow supported our efforts to permanently fix the Medicare formula for reimbursing physicians. She and a number of her colleagues are trying to formulate legislation that would offer an alternative to the Republican liability reform being pushed by Dr. Frist, Majority Leader of the Senate. She also reviewed the budget problems Washington faced on Medicaid and the Medicare pharmacy bill, which she did not support and hoped would be amended significantly.

The Michigan Insurance Commissioner Linda Watters, asked the judge in Lansing handling the OmniCare and Wellness Plan HMO rehabilitation to approve the sale of both plans. A number of objections were raised by MSMS and a number of other organizations.

Editorial: The Promis That Is Progress
By JOSEPH WEISS, MD
Editor
In January, The Wayne County Medical Society created a Task Force to focus on recruitment of primary care physicians for the Detroit area. Dr. Robert Jackson, himself a family practitioner from the downriver area, chairs the Task Force. Besides running his own private practice, Dr. Jackson has personal experience in giving care to people without insurance, and recruiting fellow physicians to help in this effort.

Initially, the Task Force identified barriers that recruiters need to overcome to bring primary care doctors to Detroit. The major barriers are obtaining money to offset practice start up costs and providing an insurance network able to generate adequate reimbursement to pay expenses and provide the practitioner a reasonable income. Other problems facing recruitment include creating a safe and pleasant work environment, a relationship for the practitioner with hospital services and specialty referral, and malpractice coverage.

The Task Force also looked into the question of how primary care should be organized. The decision was that the best approach to building and maintaining the primary care clinics was through the Wayne County Primary Care Capital Corporation, a non-profit group with links to the Detroit Wayne County Authority Development Committee.

At a subsequent meeting with a representative from the Detroit Wayne County Authority, The Task Force made a strong presentation on the need for physicians connected to clinics as opposed to attempting to recruit individual physicians for private practice. After the presentation, the WCMS was asked to join them. At its regular Wednesday night meeting on May 5, the WCMS Executive Committee approved both cooperation with the Wayne County Primary Care Corporation and the nomination of Dr. Jackson to serve on the Detroit Wayne County Authority Development Committee.

These actions by the Task Force and the WCMS define us. No federal or even state medical organization could act so carefully and forthrightly within the Detroit medical community. It takes the local society, in this case WCMS, to bring forward the physicians who understand the city, and the medical, political, and financial issues within the Detroit community. Only a local group could recruit physicians who have walked the streets and know the neighborhoods that need assistance. Only physicians who work in the area can judge what problems confront local care, and what resources are available to meet those problems.

Therein lies the promise: that the WCMS, through its members and its understanding of the medical community will act as an instrument of progress.

If you care to ask why we need a county medical society, then come to Dr. Jackson and his Task Force. They will give you an answer by example.

Duffers drive and dine at WCMS annual outing
By BRIAN BUDOWICK
& LINDA MASTERS
WCMS Staff
For the first time in years Mother Nature smiled upon the WCMS Foundation's annual Golf Outing and provided a beautiful day May 10 at the Essex Golf and County Club in LaSalle, Ontario.
Sixty-four golfers teed-off at the l p.m. shotgun start. Along with WCMS members and guests, this year's field included five Lions' alumni players. Friendly competition was ongoing throughout the day at each of the par 3 holes for the shot closet-to-hole, which won the lucky golfer a split of the pot with the Foundation. The winners for closest to the hole were Dr. Tom LaLonde, Dr. Robert Schwyn and Ken Teeters. In addition, a putting contest was held following the round of golf; the winner of the putting contest was none other than our Golf Outing Co-Chair, Dr. Joe Beals.

Cocktails were served on the patio overlooking the course followed by a delicious prime rib dinner in the beautifully appointed Essex dining room.

Representatives of RENZI custom made clothiers, acted as "spotters," awarding RENZI custom made shirts to the woman and man golfers closest to the 6th hole. Dr. Susan Van Dellen and Detroit Lions alumnus, Horace King were the lucky winners. Other sponsors of the event were Ms. Katie Spillane-Knight of the National Kidney Foundation of Michigan and Mr. Douglas M. Wood.

Allen Hughes, a former Lions player, donated a football along with two tickets to the Lions' Alumni Suite at Ford Field for any Lions game during the next season and an invitation to attend an Alumni Meeting where the winner could have the football autographed by all alumni present. Winner of the raffle for the Lions' package was Dr. Steve Rotter of Oakwood Hospital. A number of golf items, equipment, clothes and framed prints were part of a silent auction held during the evening's festivities.

All had a memorable time and we look forward to the WCMS Foundation 12th Annual Golf Outing on May 9, 2005, at the Essex Golf and County Club. Please mark your calendars!

OBITUARY
John M. Battle, MD
1926-2004
“…I will go Lord, if you lead me.  I will hold your people in my heart.”
We bade farewell to Dr. John (Jack) M. Battle on St. Patrick’s Day earlier this year. He practiced for over 50 years in Dearborn, Belleville, and Westland. During that time, he touched the lives of thousands of patients, physicians, residents, and medical students. In 1971, he became certified in the then-new specialty of Family Medicine. He was one of the founders of the Oakwood Family Practice Residency Program and its first Family Practice Center in Belleville. He served as Family Practice Program Director, Director of Medical Education, and Vice-Chief of Staff for Oakwood Hospital and Medical Center in Dearborn. Dr. Battle served the family of Family Medicine through the Michigan Academy of Family Physicians, serving as President from 1991-1992. In 1994, he was named the Family Physician Educator of the Year. After his retirement, he continued to touch Family Practice residents and faculty by continuing to teach at the Family Practice Centers in Belleville and Westland. Dr. Battle held all those he touched in his heart, and will be remembered fondly by those lucky enough to have called him physician, teacher, mentor, colleague, or friend. We will hold his memory in our hearts.
-David Walsworth, MD

Coding tips and deadlines for doctors
CMS has issued instructions to carriers to eliminating the 90-day grace period formerly allowed after new CPT HCPCS and ICD-9-CM codes are issued.

You must start using ICD-9-CM 2005 codes from Oct. 1 and CPT/HCPCS 2005 codes from Jan. 1 and you must stop using discontinued codes on the same dates.

Effective Oct. 1, 2004 for ICD-9-CM and Jan. 1, 2005 for CPT/HCPCS, providers will no longer have a 90-day grace period to use discontinued CPT, HCPCS and ICD-9-CM codes. Use of such codes to bill services provided after the date on which the codes are discontinued will cause your health insurance claims to be returned and not paid. In essence, CPT, HCPCS and ICD-9-CM codes must be valid at the time the service is rendered.
Providers should be aware that effective Oct. 1, 2004 for ICD-9-CM codes and Jan. 1, 2005 for CPT/HCPCS codes, Medicare Carriers, DMERCs, and Fiscal Intermediaries will no longer accept discontinued ICD-9-CM codes for dates of service Oct. 1 through Dec. 31 or discontinued CPT/HCPCS codes from Jan. 1 through March 31 as they did previously. This change is due to the HIPAA Transaction and Code Set Rule requiring all code sets to be valid at the time of reporting.

To protect your practice from health insurance claim denials, you need to prepare for this policy change.

Order the 2005 CPT, HCPCS and ICD-9-CM code books as soon as possible to make sure you have the new codes prior to the implementation dates.

Update your charge tickets, code lists, and computer systems to reflect the code changes prior to the implementation dates.
Start using the new ICD-9-CM 2005 codes for all services rendered on or after Oct. 1, 2004 and the new CPT/HCPCS codes for all services rendered on or after Jan. 1, 2005, and stop using any discontinued codes at the same times.

Blues commit to physician relationships, accountability, physician input is key
The MSMS Board of Directors' Health Care Delivery Committee heard from Thomas L. Simmer, MD, Chief Medical Officer and Senior Vice President of Health Care Programs and Provider Services, and Susan L. Barkell, Vice President of Provider Services, that Blue Cross Blue Shield of Michigan is launching a renewed and reorganized Provider Affiliation Strategy to address the concerns of physicians and their staffs, including rejections and delays, coding changes without notice and the Blue Cross computer system. This renewed strategy represents a commitment to structural changes, time frames, measurements and accountability. (See steps below to keep this momentum going.)

This development is the result of many individual and organizational efforts to challenge Blue Cross on the business relationship it has with physicians. Those efforts include advocacy through medical society staff and Board leaders; proposed legislation; Wayne and Oakland County medical societies' town hall meetings, and Genesee County Medical Society's physician meetings with Dr. Simmer and the Blues' provider consultants. MSMS also hosted meetings between several specialty societies and Dr. Simmer, resulting in resolution of some important claims processing and payment policy issues.

Some of the changes outlined by the Blues already are underway, and initial feedback indicates that these changes are being felt. Physicians of the Oakland County Medical Society have been able to connect to Blues consultants for information and follow-up; the leadership from the Michigan Chapter, American College of Obstetricians & Gynecologists is organizing to tap into the new Blue Cross specialty liaison process; Pathology leaders have discussed critical payment changes that are being addressed; Endocrinologists were able to get a diabetic supply issue clarified quickly, and Anesthesiologists are being notified that Blue Cross is modifying the McKesson rule regarding payment for fluoroscopy.

Physician and Staff Involvement is Key
MSMS, county societies, specialty societies, physician groups and individual physicians all have a role in making sure that this momentum is built upon. The following steps are ways to do so:
A. ATTEND SUMMITS FOR INFORMATION: Blue Cross Blue Shield will hold two "summit meetings" to explain their new commitment to accountability. The first will be on Tuesday, June 8, in Detroit and the second will be on Tuesday, July 20, in Grand Rapids. Both meetings will be held at 6 p.m., with venues to be announced. Watch Medigram or e-mail messages for details. All MSMS members, physician group managers, billers and others will be invited, and are encouraged to attend.
B. MEASURE PERFORMANCE: Blue Cross will be working with physicians to identify the appropriate measurements to verify their servicing commitments. MSMS will inform members of those measurements and report performance on a regular basis.
C. PHYSICIAN FEEDBACK: The new Provider Affiliation Strategy represents a reason to be cautiously optimistic, and MSMS needs your help in validating whether real change is occurring over time. Payer Solutions Network (see E below), the MSMS Reimbursement Advocate, specialty societies, the MSMS Board of Directors and MSMS committees all provide ways for you to tell us your experiences and allow MSMS to develop a report card on progress.
D. USE THE NEW/IMPROVED PROCESSES: If you have claims issues, now is the time to let us know. If you do not know whom your Blue Cross provider consultant is, you need to get his or her name and use them. If you deal with third-party payer issues for your specialty, take advantage of the new specialty liaison process and tap into MSMS support for those efforts. Do not let the fact that previous efforts have left you and your staff frustrated stop you. We have the attention of the Blues as never before, and we need to take full advantage of that opportunity.
E. STAY INFORMED/REGISTER YOUR EXPERIENCES: MSMS has launched the Payer Solutions Network, an e-mail communication network that will help us disseminate information to many offices at once and provide us with an easy-to-use mechanism for collecting hassle-factor complaints, including requests for help from the MSMS Reimbursement Advocate, a service that is free to members. To register for the Payer Solutions Network, send an e-mail message with your NAME and E-MAIL ADDRESS (and the name of the MSMS MEMBER YOU WORK FOR, if you are not a member physician) to msms@msms.org and entering "Payer Solutions Network" in the subject line.