Physicians show their clout with Texas MCO
Physicians show their clout with Texas MCO
CIGNA drops unpopular coding system
Texas physicians are working to be on the front lines of a trend in which doctors fight managed care changes and actually win.
Houston-area specialists convinced CIGNA Healthcare of Texas in Houston to drop a coding system that would pay physicians an across-the-board Level 3 CPT code rate for all office services. Before CIGNA agreed to overturn the change in October, the new coding system had been put into effect for several months for about 300 general surgeons, urologists, plastic surgeons, and otolaryngologists.
The battle over downcoding, as it’s called, is symbolic of the struggles physicians have had in recent years with managed care organizations (MCOs) and their attacks on reimbursement rates, one Texas physician leader says.
"Basically, MCOs have cut reimbursements dramatically, and that has resulted in a deepening of the health care crisis," says Paul B. Handel, MD, urologist and president of the 8,000-member Harris County Medical Society in Houston. Handel also is vice chairman of the Council for Social Economics for the Texas Medical Association (TMA) in Austin.
Handel says he’s dealt with MCOs that want to reimburse physicians at rates lower than what Medicare pays. Yet Medicare rates already are so low that some Houston internists have closed their offices because their practices were dependent on Medicare patients, and they couldn’t meet their overhead costs, he adds.
Downcoding is particularly galling to physicians because it means they will be paid the same amount for every office visit whether they spend 10 minutes or an hour with a patient, Handel says.
"Physicians need to be paid for the services they render," Handel says. "If they render a service of $75, they shouldn’t be paid a $25 code."
CIGNA also dropped its third-party administrator (TPA), Miami-based Allied Health Group, which is owned by Magellan Health Services, a publicly traded company based in Atlanta. Allied had received a capitated fee from CIGNA, and the TPA paid specialists on a fee-for-service basis.
Allied Health Group had proposed a Level 3 coding system to solve a common specialists’ complaint of having too much overhead, says Erin Somers, director of media relations for Magellan in Columbia, MD.
A physician panel assembled by Allied Health Group proposed billing specialists one CPT coding level instead continuing with the Level 1 through 5 CPT range.
With the Level 3 coding change, specialists would not be required to submit documentation to support their claims, which would cut down on paperwork.
"Physicians told us they were spending too much time reviewing charts to see if someone had coded it incorrectly," says John Seidenfeld, MD, vice president and medical director of CIGNA HealthCare of Texas.
Handel says managed care has made medical documentation much too complex. "We have added 1.5 full-time employees to our practice just to deal with administrative headaches, hassles, and hoops that we have to jump through because of managed care," he says.
However, one payment rate is not the solution, Handel says. "When physicians found out about this change, they were very unhappy."
So Handel and other physicians began to complain about the change, convincing CIGNA to meet with the doctors, the Texas Medical Association, and Texas insurance department officials to discuss the problem.
The Texas Medical Association polled specialists, asking them if they’d prefer the Level 3 system or the five CPT levels. They clearly indicated they wanted to be paid for the work they did, says Bradley Reiner, assistant director of health care financing.
Seidenfeld says he believes physicians were equally divided between supporting and opposing the Level 3 coding system. But CIGNA decided to switch back to the five-level system to maintain good relations with Houston-area specialists.
CIGNA’s cooperation gives more clout to physicians who continue to face battles over downcoding, Reiner says.
"TMA has had success with other payers in rescinding their downcoding policies," Reiner says. "We’re trying to set a precedent here with CIGNA’s being receptive to changing their policy."
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