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April 6, 2009 |
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IN THIS ISSUE
Editor's Column: Why We Need Government
In My Opinion: Health Care: Philosophy Versus
Policy
Task Force Against Violence Open House April 13
Fifth Annual James C. Hazlett, Jr. Memorial Golf
Outing
Health Authority Organizes Free Sports Physicals,
Well Child Care
Cigna Claims Crunch Begins April 20
WellPoint Targeted In Physician Class Action
Lawsuit
AMA to Senate: Make Health Insurer Payments More
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Editor's Column: Why We Need
Government
(Editor's Note: The last three items in this newsletter relate
somewhat directly to the points raised in this column and evidence
what appears to be a growing problem.)
By JOSEPH WEISS, MDLikely most physicians are aware of the lawsuit filed in
January by the New York State Attorney General against United Health
Care and its subsidiary Ingenix. The basis of the suit was that
United Health Care had set up Ingenix as a front to create an
artificially low data base of customary medical fees. The purpose of
the rigged data was to underpay doctors and force higher bills on
patients who went to out-of -network physicians.
This rigged system existed for years until the New York
Attorney General, following the complaints of New York state
residents, found that Ingenix set an out-of-network physician visit
as averaging $67. Patients in United Health Care, or other insurers
such as Aetna who used Ingenix, were told that the insurance
companies would pay 70 percent ($48) but the rest of the bill was
the patient’s responsibility. The New York Attorney General’s
investigation found that $150 was the true average out-of-network
fee, and that patients insured by United Health, and Aetna should
have received $105, and paid out-of-pocket only $45. Until the New
York State Attorney General stepped in, patients received only $48
and paid $102 out-of-pocket. A by-product of the Ingenix scheme was
that out-of-network physicians were made to look greedy as their
$150 charge seemed unreasonable compared to the $67 that Ingenix
reported as the usual and customary fee.
In the settlement of the Ingenix case, United Health paid a
fine of $350 million, and Aetna is in court trying to avoid a
similar fine for acting in collusion with United Health Care in
establishing the bogus pricing.
The Ingenix case illustrates one role of government in
health care: to act as an opposing force to excesses in the
marketplace. United Health Care’s scheme was exposed only because of
a government investigation and stopped because of government
intervention. Government stepped in to restore a fair marketplace.
Few would argue that government alone, without a
marketplace, creates an ineffectual economy. However, those who call
for an end to government in health care need to tell us who else
will prevent and correct corruption in the marketplace.
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In My Opinion: Health
Care: Philosophy Versus Policy
By ALLAN
DOBZYNIAK, MD
What is the difference between controlling human (physician)
behavior by central edict or controlling human (physician) behavior
by economic disincentives? Either way, physicians have lost their
freedom and free markets have been ravaged. Physicians can no longer
function except by accommodation with government.
The claim is that
these decisions pertaining to government-managed, universal health
care are made because they are moral and produce the greatest good
for the greatest number. I am unaware of the issuance of a patent on
morality or that its definition has yet to be fixed in stone. We can
only hope the decisions are not driven by utopianism and idealism
that is really a wacko visionary plan for the betterment of mankind.
A presumption of moral superiority eliminates boundaries in what
will not be done in pursuit of “good.” Sometimes the questions are
more important than the answers, or we risk being manipulated as we
are marched through a labyrinth of deception.
Let us hope that
freedom will not become an enshrined illusion. If I remember my
history, such systems have only been vivid examples of past
failures.
Remember, it
can’t be ordered if it is not on the menu.
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Task Force Against
Violence Open House April 13
Wayne County
Task Force Against Violence Open House
April 13 - Noon-2 p.m.
Lunch Provided
WCMSSM Headquarters
New Center One Building
3031 W. Grand Blvd., Suite 645
Detroit, MI 48202
Please RSVP by April 10, 2009
Peggy Mitchell
(313) 874-1360 ext 10
pmitchell@msms.org
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Fifth Annual James
C. Hazlett, Jr. Memorial Golf Outing
Spots are filling up! Register
online @
http://www.golfdigestplanner.com/11468-HazlettMemorialGolfOuting
Payment and registration can also be dropped off at Student Affairs
The 5th Annual James C. Hazlett, Jr.
Memorial Golf Outing
Bringing together students, faculty, alumni, and friends
of Wayne State University School of Medicine
Saturday, May 2, 2009
Twin Lakes Golf and Swim Club
455 Twin Lakes Drive
Oakland Township, MI 48363
Come out for the awesome golf, tasty dinner buffet,
and prizes - including Winning Team, Longest Drive,
Closest to the Pin, and tons of raffle giveaways!!!
Proceeds help to support the James C. Hazlett Jr. Medical Student
Scholarship fund, graduation expenses for senior classmen, and the
philanthropic student organizations of Wayne State University School
of Medicine who actively volunteer in the Metropolitan Detroit
community.
An associate professor of anatomy and cell biology, Dr. James
Hazlett, Jr. joined the WSU faculty in 1980, and was instrumental in
the design and implementation of the medical school curriculum. He
served as course director for medical neuroscience and gross anatomy
- two critically important comprehensive areas that are required of
all medical students. In addition, he taught human body dissection,
anatomy, neuropharmacology and neuroanatomy in the School of
Medicine. In 2001, he was named assistant dean after serving many
years on the Admission and Curriculum Committees, which then allowed
him to play a critical role in the development of the Year I and II
medical doctorate programs.
The James C. Hazlett Jr. Memorial Scholarship Fund and Annual Golf
Outing were established in honor of Dr. Hazlett's deep commitment to
medical education and student success after his death on February
22, 2005. For more information or to donate to the fund, please
contact Terri Larrew at 313-577-8311.
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Health Authority Organizes Free
Sports Physicals, Well Child Care
April 13-17, 2009
8 a.m. to 2:30 p.m.
Northwestern High
School—School Based Health Center Room A- 300
2200 W. Grand
Boulevard
Detroit,
Michigan 48202
To Schedule an
Appointment Call (313) 596 0700 x388
Walk-in’s are
Welcome
Editor's Note: The following is a letter from Detroit Wayne County
Health Authority CEO Chris Allen.
This
collaborative effort will support the athletic programs of
ThinkDetroit PAL and other school and community based sports
programs. In addition to the free physical, the first 100 youth
each day will receive sports backpacks, all youths will be able to
attend workshops on nutrition and chronic diseases such as asthma
and diabetes, as well as have a chance to take advantage of an array
of fun filled activities.
For uninsured and
underinsured participants, the Health Authority staff and volunteers
will facilitate Medicaid enrollment through information, screening
and application assistance. As many as one in seven adolescents
have no health insurance. One in three low income adolescents are
not covered by Medicaid. More importantly private insurance
coverage of adolescents is increasingly restrictive. The book Great
Transitions: Preparing Adolescents for a New Century recommends
expanding school-linked health services. This is one of the
reasons the Health Authority will continue to offer support to one
of our most valued safety net partners, school based health centers.
During these
difficult economic times, it is more important than ever that the
Health Authority take a leadership role in ensuring access to health
care. As part of the Health Authority’s Team, we ask you to help
“get the word out” about this important event. The co-sponsors of
this event are the southeastern Michigan Medicaid Health Plans:
Health Plan of Michigan, Midwest Health Plan, Molina Healthcare,
Great Lakes Health Plan, Omni Care, and Pro Care Health Plan.
I hope we can
count on you!
Sincerely,
Chris Allen
Executive Director and CEO
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Cigna Claims Crunch
Begins April 20
It has come the
attention of the Detroit Medical News that the major insurer Cigna
will begin requesting documentation with certain claims as part of a
new software application called "Claim Check 8.5 Knowledge Base
Version 42.
The information
comes to DMN though Christie Dando, who chairs the Communications
Committee for the Michigan Medical Group Management Association.
She stated in an
e-mail: "For
all claims on or after April 20th, Cigna will start
requesting office notes for any claims that have modifier 25
attached on an E/M visit or modifier 59 attached to a procedure.
According to the information we received, Cigna will allow an E/M
visit to be billed in addition to a procedure, but they will require
'supporting documentation' before they pay for the E/M visit
appended with modifier 25.
"Worse yet, any claims billed with modifier 59 will
also require supporting documentation before that procedure is paid.
"This appears to be another way for a payer to delay
payments to providers. Being required to send manual claims with
office notes and/or op notes attached will delay speedy payment by
months and put an undue burden on our billing staff."
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WellPoint Targeted
In Physician Class Action Lawsuit
In an expansion
of its ongoing effort to expose and prohibit an industrywide health
insurance scheme to defraud patients and physicians of proper
reimbursement, the AMA announced March 25 it is among several
medical societies that filed a class action lawsuit against
WellPoint Inc., the largest health insurer in the United States.
The lawsuit,
filed in Los Angeles federal court, alleges that WellPoint colluded
with others to underpay physicians for out-of-network medical
services, resulting in patients paying an excessive portion of the
medical bill. The AMA filed similar class action lawsuits last month
against Aetna Health Inc. and Cigna.
“Physicians will
not tolerate an apparent conspiracy that allows health insurers to
play by their own rules without regard to patients, or the
legitimate costs required to care for them,” said AMA President
Nancy H. Nielsen, MD, PhD.
The Litigation
Center of the AMA and State Medical Societies is supporting the
WellPoint lawsuit in partnership with the California Medical
Association, the Connecticut State Medical Society, the Medical
Association of Georgia and the North Carolina Medical Society.
Visit
http://www.ama-assn.org/ama/pub/news-events/news-events/class-action-wellpoint.shtml
to read more from Dr. Nielsen.
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AMA To Senate: Make
Health Insurer Payments More Transparent
The AMA testified
today to the U.S. Senate Committee on Commerce, Science and
Transportation on the need for increased insurer payment
transparency. Congress can help restore reasonable compensation for
the patients and physicians who were shortchanged by insurers and
promote fair and accurate payments going forward. This follows
recent legal settlements with insurers for underpayment of
out-of-network care.
“We encourage
Congress to pursue increased transparency of all health insurer
payments to improve efficiencies and savings throughout the health
system,” said AMA President Nancy H. Nielsen, MD, PhD. “Making the
insurance payment system more transparent will help keep
the patient-physician relationship intact, as it can
be threatened if patients perceive that their physician is
overcharging for services when in reality the insurer is
underpaying.”
Visit
http://www.ama-assn.org/ama/pub/news-events/news-events/health-insurer-payments.shtml
to read more about the AMA’s testimony.
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