 January 2003 • Volume 9 • Number 1 |
 *Reported to the AAFP via the online Health Plan Complaint Form. |
Open the door just a crack -- and a peek inside the world of third-party payers sheds light on some poor payer habits. In October, the Academy asked members to participate in a collaborative project it was undertaking with the AMA and other medical associations. Project organizers encouraged physicians to air their complaints about third-party payers via an online Health Plan Complaint Form. Complaints are still being collected; it's not too late to participate.
The first batch of specialty-specific data, recently reported to the Academy, revealed that 35 members had generated 79 complaints against 22 identified plans (and 12 unnamed plans). The largest number of complaints were filed against HMOs, the next largest number against PPOs.
Which plans gave FPs the most hassles? United Healthcare ranked worst, followed by Cigna HealthCare and Aetna. The highest volume of complaints originated from Ohio and Texas; however, 11 forms had no state designated.
The number one physician complaint was "denial of modifier," followed by "bundling of services" and payer "late payment."
More specifically, payers' treatment of the CPT "modifier 25" drew the most ire under the denial of modifier category. According to CPT, modifier 25 is applied when a physician requests payment for a "significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service."
The Academy urges members to continue to file complaint forms at http://www.aafp.org/complaint.xml and requests that members fill out the form in its entirety.
The feedback will serve as a road map for the Academy, said James Bare, policy analyst in the AAFP Socioeconomics Division. "Complete answers will allow the Academy to craft responses and pursue initiatives with clear direction and purpose, helping us to use our resources wisely as we search for solutions to these problems."
All physician information will remain confidential. The duration of this project, and the frequency with which the results are released, will depend solely on the volume of responses received.
FP Report is published by the
AAFP News Department.
Copyright © 2003 by
American Academy of Family Physicians.