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Fam Pract Manag. 2005;12(10):26-27

Humana settles with physicians

Humana has become the sixth insurer to settle its part of a class-action lawsuit brought by physicians over allegations that insurers unfairly denied or delayed reimbursement. At press time, settlement approval hearings had not yet taken place and details were pending. As with the other settlements, the insurer will provide physicians a mechanism for seeking limited compensation and will be required to change some of its business practices.

UnitedHealth Group, PacifiCare Health Systems and Coventry Health Care have not settled the case and are expected to go to trial in January.

Quote. Endquote.

“You are a surgery patient. You have been stripped naked and stuck with needles. The people in charge are strangers... yet they are about to knock you unconscious and cut open your body. how important is it that you trust the hospital and the people who work there?”

– David Shore, MD, founding director of the Harvard School of Public Health Trust Initiative, in his book The Trust Prescription for Healthcare: Building Your Reputation With Consumers.

Health plans vs. banks: Who treats their customers better?

Percentage of patients who agree with the following statements:

My primary health plan or primary bank ...Health planBank
Goes out of its way to protect my privacy3452
Always honors its promises2860
Is always on my side for problems/concerns1950
Makes things more complicated than necessary3212
Requires government regulation to do what’s right2012
Seems reluctant to assist me1512

Delegates debate recertification, health plan hassles, retail clinics

At its recent annual meeting in San Francisco, the AAFP Congress of the following:

Maintenance of certification. Some delegates argued that the AAFP should advocate to reduce the number of self-assessment modules from six to three per recertification cycle and seek other venues of certification should members choose not to recertify through the American Board of Family Medicine’s (ABFM’s) new process. However, the Congress opted for a more moderate resolution. It called on the AAFP to “continue to strongly advocate for meaningful change” in the maintenance of certification process and educate members about the advantages of maintaining their certification.

Coding. The Congress voted to amend the AAFP’s current policy on coding and reimbursement to include the following statement: “It is not acceptable for health plans to threaten to restrict, terminate or exclude a family physician from plan participation based on his or her coding pattern if the family physician provides medically necessary services and conscientiously abides by the principles and rules of CPT coding.”

Health plan clearinghouse. Delegates voted to develop a national clearinghouse to collect data regarding undesirable business practices of health insurance companies, and they asked the AAFP to identify trends in the data and address those issues with insurers. The resolution also called on the AAFP to work with the AMA to ensure that health plans adhere to CPT coding guidelines.

Uncompensated services. Delegates adopted a resolution to “explore models of compensation to pay for non-direct patient care and other administrative tasks,” such as referral processing and preauthorization.

Retail health clinics. Delegates asked the AAFP to investigate the “growing phenomenon of retail health clinics,” such as MinuteClinics in Target stores, and to educate members so they will be prepared if such clinics begin to compete in their local markets.

Project focuses on billing complexities

Even David Brailer, national coordinator for health information technology in the Department of Health and Human Services, has trouble interpreting health care bills. Speaking in the Oct. 13 New York Times, he said, “I’m the president’s senior adviser on health information technology, and when I get an EOB for my 4-year-old’s care, I can’t figure out what happened, or what I’m supposed to do. I can’t figure out what care it was related to or who did what.”

He likens the process to patronizing a restaurant that doesn’t reveal its prices. “Then, weeks or months later, you get a bill that tells you all the food you ate and the drinks you had, some of which you remember and some you don’t, and although you get the bill, you still can’t figure out what you really owe.”

Several organizations, led by the Healthcare Financial Management Association, are trying to address these issues via the Patient Friendly Billing Project. Their aim is to make health care bills clear, concise, correct and patient friendly.

Study finds modest improvement with P4P programs

Paying medical groups for reaching performance targets “may produce little gain in quality for the money spent and will largely reward those with high performance at baseline,” according to a study published in the Oct. 12 Journal of the American Medical Association. Researchers compared the performance of a physician network that was offered bonus payments to the performance of a network that was not offered bonus payments. Out of three measures studied, the bonus group outperformed the non-bonus group on one measure, cervical cancer screening, with improvement rates of 5.3 percent and 1.7 percent, respectively. On the other two measures (mammography and A1C testing), both groups showed modest improvements, but the differences were not significant.

Among the bonus group, those with the worst baseline performance showed the most improvement but received the smallest payouts. In contrast, those already performing at or above the targets at baseline received the largest payouts but improved the least. Researchers suggested that carefully designed incentive programs could reward both high performance and improvement.

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Copyright © 2005 by the American Academy of Family Physicians.

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