It's not always a slam dunk that family physicians will be paid for performing certain procedures; sometimes they have to fight for recognition from insurers. One physician in Michigan recently did just that -- and won.
Andrew LaFleur, M.D., of Saginaw, learned earlier this year that he would no longer be paid for performing colonoscopies. Why? Because HealthPlus of Michigan,(www.healthplus.org) which for years had been paying him for the procedures, merged earlier this year with Health Alliance Plan (HAP). Shortly after the merger, HAP sent LaFleur a notice regarding new payment policies.
Bad news: The merged company said it would pay only general surgeons, gastroenterologists and colorectal surgeons who were affiliated with HAP facilities to perform colonoscopies.
Seeking advice, LaFleur called fellow Michigan FP John Pfenninger, M.D., of Midland. Pfenninger, a long-time advocate for better payment for primary care physicians, urged LaFleur to pursue his case with the insurer.
- Michigan family physician Andrew LaFleur, M.D., learned earlier this year that he would no longer be paid for performing colonoscopies following a health insurance merger that changed the merged company's payment policies.
- After months of paperwork and jumping through administrative hoops, the insurer notified LaFleur in June it would allow him to bill for the procedure.
- The Michigan AFP and the Academy provided assistance by contacting company leaders and a state legislator in an attempt to secure a policy change.
Taking on Goliath
LaFleur, who opened his private practice in 2008, is board-certified in family medicine and specifically trained to do colonoscopies. He also performs in-office injection procedures and vasectomies, as well as intrauterine device insertions, and has historically received full payment for those procedures with no dispute.
Other insurers he contracts with -- including Blue Cross Blue Shield of Michigan, Priority Health and Medicare -- all pay him for colonoscopies. HAP is the only carrier to date that has refused to pay him for this procedure.
When he first learned that the payment policy would change after the merger, LaFleur contacted the insurer to request an exception. HAP officials directed him to submit substantial documentation to the insurer's credentialing committee.
"I had to jump through all these hoops," LaFleur told AAFP News. "It took a lot of time."
Finally, in June, HAP notified LaFleur that it would allow him to bill for the procedure. He had continued to perform colonoscopies while waiting for a decision, and he anticipates that he can bill retroactively for the procedures.
"I think it's unfortunate that insurance companies make policy about who gets paid, and they are either not aware of or ignore the fact that family physicians are trained to do these procedures just as well as, if not better than, (sub)specialists," LaFleur said.
Interestingly, HAP is owned by the Henry Ford Health System, a subspecialist-based health care system. Blue Cross, Priority Health and HAP are the dominant insurers in the state.
Help Pours In
The Michigan AFP, as well as the AAFP, assisted LaFleur in his efforts by contacting HAP leaders and State Rep. Edward Canfield in an attempt to secure a policy change. The chapter took action through its ad hoc committee on payment and delivery system reform.
In letters to HAP Senior Vice President and Chief Medical Officer Numa Munir, M.D., a family physician, the two organizations clearly stated their objections.
Citing the insurer's stated policy that the procedure can only be performed at HAP-affiliated facilities by select subspecialists, the Michigan AFP's letter argued that only hospital governing boards, with medical staff input, determine who should be granted colonoscopy privileges at their institutions.
"This decision should be based solely on the candidate's ability to meet established criteria, including training and/or experience, demonstrated abilities and current competency, and not on the physician's specialty," the chapter said in its June 7 letter. "Ultimately, it is beyond the purview of payers to determine who is granted clinical privileges."
"Privileges should be granted to all physicians commensurate with their documented training and/or experience, demonstrated abilities, and current competence," agreed the AAFP in a letter sent June 9 in which it called on the insurer to "reconsider the exclusionary criteria based solely on a physician's specialty rather than demonstrated current competency so that family physicians can perform a colonoscopy."
Michigan AFP President Robert Jackson, M.D., of Allen Park, argued that payment for specific procedures -- including colonoscopy -- should be based on training and experience rather than on rigid policy that limits payment to certain subspecialties.
Unfortunately, many insurers have an inherent bias in favor of subspecialists performing procedures that family physicians are more than qualified to do, said Jackson. One of his family physician colleagues is married to a nurse practitioner who works full time for an orthopedic surgeon and part time for her husband. She performs hyaluronic knee injections in the orthopedist's office, which is reimbursed for the procedure, but cannot do the same in her husband's practice.
"The same injection is not allowed in the family physician's office," Jackson said. "It's not a matter of training and experience, and it's not a matter of quality."
HAP informed Jackson and his FP colleague that it would pay them only for the injection and not for the medication, which costs several hundred dollars. Only orthopedic surgeons, rheumatologists and rehabilitation physicians are eligible for full reimbursement, according to the insurer's policy.
"The moral of the story is state associations need to develop relationships with the payers in the state," said Jackson. "We need to fight this going forward and make sure they are paying us in accordance with our value."