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November 19, 2007 |
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IN THIS ISSUE
Editor's Column: United Healthcare: Who's United, Whose Health
and Who Cares?
Dean
Mentzer Announces New Leaders At WSUSOM
HFHS Clinic
Receives National Recognition
The Doctors Are In! MSMS
Hosts Town Hall Meetings
MSMS Conducts EMR Case Studies
Blue Cross
Trust Discussions Drawing To Successful Close
Health Insurance Scams Target Small Businesses, Individuals |
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Editor's Column: United Healthcare: Who's United,
Whose Health and Who Cares?
By JOSEPH
WEISS, MD
In late September I received a letter from United Healthcare stating
that it wanted to update me on my “designation status” within their
organization. The letter instructed me to go to
http://ereports.uhc.com/ReportCard to obtain an assessment of my
performance. I did so. I encountered the usual problems of getting
my user ID and temporary password to work. In my case I couldn’t
enter the website and it took a call to United Health to learn the
website was “down” and I should try again in three days, which I
did.
Eventually, I found my designation report. It contained
numbers, headings and abbreviations in large black letters, few of
which made sense to me. My list included patient C.M., a woman with
lupus. The accompanying information stated that from the period of
September 2005 through January 2007 the cost of my care was $4,157,
while the expected cost was $1,648.37.
A check of this patient’s office records revealed I first
saw her in :April 2006 and last saw her in November 2006; she had
four visits in total, my average reimbursement was approximately
$53/visit. Therefore, so I thought, I had a good case to request a
revision of my designation report, based on the obvious errors in
it.
I needed to work through a series of phone numbers and
conversations that eventually led me to a Designation Specialist; he
informed me that the report was correct. Though I received
approximately $200 for her visits to me, the effect of “attribution”
meant that the $200 I received equated to $4,000 of responsibility.
According to the United Healthcare manual: “Rules of
attribution are used in assigning enrollee services and episodes to
a responsible physician. ( p10)” United Healthcare identifies the
responsible physician as the one whose claims represent the majority
of allowed dollars paid out by United Healthcare. The manual, on
page 10, goes on to state that: “When more than one physician is
involved in a case, the physician with the majority of allowed
claims spent on the case is designated as being responsible for the
episode of care and is assigned the full cost of care.”
Though I didn’t see her until April 2006, the responsibility
of her care, as defined by the United Healthcare’s software program,
began in 2005 and extended through 2007 -- despite their agreement
that the last time I saw her was November 2006.
I asked how it was possible that my $200 represented the
largest physician claim when the total cost of her care was over
$4,000. United Healthcare replied that was how the software worked
it out. When I asked for the breakdown of the other physicians’
reimbursements, United Healthcare said that wasn’t possible as doing
so represented an infringement on the other physicians’ privacy.
When I requested a reconsideration of my designation status,
United Healthcare said they wouldn’t do it because I didn’t have
enough patients in their system to make a review worth their while.
Presently, I stand labeled, by United Healthcare, if not as
a bad physician, at least as a not so good one. The public just
assumes I am not a good doctor. I am judged by United Healthcare
software not subject to either outside review or to statistical
method. No articles exist in the medical literature to confirm the
validity of their software.
Our duty is to review our United Healthcare designation with
diligence. Find their egregious and enormous errors and then give
them hell.
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Dean Mentzer Announces New Leadership
At WSUSOM
Dr.
Robert M. Mentzer Jr., dean of the Wayne State University School of
Medicine, welcomed seven new leaders who joined the “cadre that is
committed” to Vision 2011, the school’s strategic mission.
Mentzer, at the Nov. 13 School of Medicine Faculty Fall Harvest
Reception, recognized Dr. Theodore Jones, interim chair, Obstetrics
and Gynecology; Dr. David Lawson, interim chair, Physiology; Kenneth
Lee, associate dean of Finance and Administration; Dr. Lawrence
Morawa, chair, Orthopedic Surgery; Dr. Kenneth Palmer, interim
chair, Pathology; Dr. Herbert Smitherman Jr., assistant dean,
Community and Urban Health; and Dr. Maria Vlachaki, interim chair,
Radiation Oncology.
Nearly 100 faculty members took part in the School of Medicine’s
strategic planning process, Mentzer noted. Recently completed, the
process will roll out to all departments by early January.
“Our
strategic plan lays the groundwork for an ambitious and exciting
time ahead for the School of Medicine Physician Group,” Mentzer
said.
“We
could not have reached this important milestone without the
intellectual contributions of the workgroup members, and of those of
you who guided us throughout the process.”
Dr.
Jones’ special interest focuses on treating pregnant women with
conditions such as diabetes and hypertension. He is an active
clinical researcher and an investigator for the NICHD International
Pediatric and Perinatal HIV Studies Network.
A
professor emeritus of physiology in the School of Medicine, Lawson’s
research focuses on integrative responses of experimental rodents to
common experimental manipulations and housing conditions. He served
21 years as a member of the WSU Institutional Animal Care and Use
Committee, including chairing the organization.
Lee
joined the School of Medicine leadership team in 2006 and, since
June, has served as interim chief operating and financial officer
for the WSU Physician Group. He most recently served as chief
administrative officer and director of clinical business affairs for
the University of Kentucky School of Medicine.
Dr.
Morawa has served on the faculty of the School of Medicine’s
Department of Orthopedics since 1974. His research and publications
have made him a much sought after speaker nationally and
internationally.
Dr.
Palmer was the first director of the M.D./Ph.D. program at Wayne
State University. He was recruited from Boston University School of
Medicine and the Mallory Institute of Pathology.
Dr.
Smitherman’s research focuses primarily on health issues related to
underrepresented populations of color and access to care. He has
invested the last 21 years in working with diverse communities in
Detroit to develop urban-based primary-care delivery systems.
Dr.
Vlachaki, who could not be present at reception, organized the
radiation oncology quality assurance program at New York
University’s department, which led to its accreditation by the
American College of Radiology. She has been active in research and
teaching, presenting her work at national and international
conferences, and has been published in well-respected journals in
the field.
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HFHS Clinic Receives National Recognition
The Neurofibromatosis Clinic at Henry Ford Hospital has been awarded
Network Affiliate Status by the Children’s Tumor Foundation. The
clinic is the only one in Michigan and one of 21 in the country to
receive this prestigious recognition.
Neurofibromatosis encompasses a set of distinct genetic disorders
that cause tumors to grow along various types of nerves. It can
affect the bones and skin and can cause tumors to grow anywhere on
or in the body.
The designation by the Children’s Tumor Foundation recognizes Henry
Ford Hospital for providing appropriate care through a consensus of
clinical care guidelines. Members of the network also aim to improve
clinical care for those living with the disorder through information
sharing and integrating clinical care and research.
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The Doctors Are In! MSMS Hosts Town Hall Meetings
MSMS is
working with county, specialty and ethnic medical societies to
coordinate "Town Hall Meetings" to inform members about initiatives
related to reimbursement, contracting, and legislation. The
30-minute presentation is available for meetings from now until May
2008. Upcoming Town Hall meetings: Muskegon County Medical Society
(Tuesday, November 20, 6:00 p.m., Muskegon Country Club), Macomb
County Medical Society (Tuesday, November 20, 6:30 p.m., Best
Western Sterling Inn Banquet & Conference Center, Sterling Heights),
and Wayne County Medical Society (Wednesday, December 12, 6:30
p.m., Hyatt Regency, Dearborn). For more information, or to
schedule a Town Hall meeting, contact Rebecca Blake at 517-336-5729
or
rblake@msms.org.
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MSMS Conducts EMR Case Studies
MSMS soon will
be releasing the results of its research project on
electronic medical records (EMR), which aims to address a gap in
current EMR research. It will include a series of case studies that
captures the actual experience of Michigan physicians as they made
decisions to use EMR and then implement them. The case studies will
include best practices and examples of those that struggled with the
decision and implementation. MSMS, with the research firm Public
Sectors Consultants, conducted 14 case studies based on practice
size, location, specialty, physician enthusiasm, stage of
implementation, use of consultants, vendors and successes. The goal
is to deliver narratives, with lessons learned, of the experience of
physicians deciding on and implementing EMR. The case studies will
be released this month. For more information, contact Rebecca
Blake at 517-336-5729 or rblake@msms.org.
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Blue Cross Trust Discussions Drawing To Successful
Close
After three
meetings with MSMS and Michigan Osteopathic Association leaders, the
Blue Cross Blue Shield of Michigan review of new Traditional and
TRUST (PPO) contracts is drawing to a successful close. MSMS and MOA
gave feedback on contract language that was either unclear or
objectionable to physicians.
In almost all
cases, appropriate explanations or agreeable changes were made.
Although Blue Cross has not yet addressed the definition of "covered
benefit," the contracts are much clearer in spelling out physician
obligations.
Physicians will
receive copies of the the new contracts in December. Watch e-mail
and Medigram for further details.
For more
information, contact Julie Novak at (517) 336-5768 or
jnovak@msms.org
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Health Insurance Scams Target Small Businesses, Individuals
The Wall Street Journal
on Sunday examined the increasing number of small employers and
individuals "searching for affordable health insurance" who fall
"victim to scams and misleading offers." According to Mila Kofman, a
Georgetown University associate professor who has studied the
issue, more than 200,000 small businesses and U.S. residents since
2000 have purchased fraudulent health care plans and were left with
hundred of millions of dollars in unpaid medical claims.
Telemarketers also have begun targeting seniors by selling fake
Medicare prescription drug plans and Medicare Advantage policies,
according to Kim Holland, commissioner at the
Oklahoma Insurance Department. Holland said some telemarketers
use the calls as a ploy to collect private data for identity theft.
Meanwhile, fake group policies for small businesses and their
employees often are "pitched through unsolicited faxes," the
Journal reports.
Medical discount cards also are "sometimes misrepresented as
insurance by unscrupulous agents and Web sites," according to the
Journal. While
legitimate discount programs can offer discounts of 5% to 25% or
more on services from a list of in-network providers, some
illegitimate programs do not have many providers in their networks
or do not provide the promised discounts.
Holland said, "It is amazing how long these things can go on before
regulators are advised of them," adding, "Until people complain, we
don't know" (McQueen, Wall
Street Journal, 11/18).
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