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Bills pit doctors against insurers -- Medical Society wantsFrom: Dean Huffman (dean@thehuffpeople.net)Thu Mar 21 15:20:15 2002
.. You might find this interesting. - - - - Bills pit doctors against insurers Medical Society wants changes in contracting practices By TONY CAPPASSO, STAFF WRITER, Springfield Journal-Register Doctors and insurers are squared off in a battle over legislation that if passed would change health maintenance organizations' and insurance companies' contracting practices. The Illinois State Medical Society, the main speaker for the state's roughly 15,000 doctors, wants the legislature to enact into law what it calls the "Fairness in Health Care Contracting Act," which it says would correct HMO and insurance company "abuses," according to Society president Dr. Ronald Ruecker of Decatur. The insurance industry has mounted a full-court press to try to block passage of two bills - House Bill 6032 and Senate Bill 1848 - that contain the Medical Society's desires. Industry lobbyists have been spreading the message around the state that enacting the provisions in the two bills would increase health-care costs to employers and consumers. In essence, the two bills contain five provisions important to Illinois doctors, according to Ruecker. Those would: - Give health-care providers 30-days notice to read new contracts. - Ban insurers from making unilateral changes to the contract once it has gone into effect. - Limit insurers to two years to recoup overpayments and require written explanations of what they're after. - Force the insurers and HMOs to reveal their payment rates to doctors they contract with. - Give doctors the right to opt out of a contract if the firm rents out its provider list, often at different payment rates and contract terms, to third parties. "We want the rules to be clearly spelled out, and we want clear, understandable information to effectively run our offices," Ruecker said. The two bills are so fraught with controversy that the legislature established a special task force to take testimony from both sides and try to hammer out an acceptable compromise. So far, it has been heavy going. "I bet I've spent 1,500 hours on this issue," task force co-chairman Rep. Angelo "Skip" Saviano, R-Elmwood Park, said Tuesday. Saviano said lobbyists for the insurers and HMOs have even gone to one of his core constituencies, Chicago-area labor unions, and frightened them with visions of unaffordable health care and employers dropping health benefits. As a result, union representatives have been pressuring Saviano on the issue, he said. "I'm a very pro-union Republican," Saviano said. "They've gone to union members and told them 'Once this is enacted, we're not going to be able to provide health care for your members, '" Saviano said. The Elmwood Park Republican said he has been stunned by the power of the insurance industry in Illinois. "They have tentacles everywhere," he said. The Illinois Association of HMOs, the Illinois Chamber of Commerce and the city of Chicago have either testified before the task force or sent proxies to do so. Further complicating the matter is a pending lawsuit against CIGNA, Blue Cross Blue Shield of Illinois and an HMO based in southern Illinois called HealthLink. The lawsuit, filed by a southern Illinois doctor, charges the firms with unfair business practices, including using a computer software program that "downcodes," that is, assigns lower payment value, to doctors' charges. Because of the suit, members of the insurance industry are reluctant to testify before the task force, fearing, they claim, that their words will come back to haunt them in court. Barbara Molloy, who runs a Chicago-based health benefits consulting firm, testified against the two bills before the task force, which is co-chaired by state Sen. Tom Walsh, R-LaGrange Park. Molloy said the problem with the medical society's concept of a "contract" between doctors and HMOs or insurers is that they approach it as if it were cast in stone. Take the 30-day review that the medical society wants the legislature to impose on HMOs. If that were enacted, it could damage the viability of doctor networks, she said. "A network of doctors is put together in advance, then marketed to employers for their employees," Molloy said. "If doctors could take 30 days to consider the contract, then just opt out at the last minute, that would destabilize networks." Similarly, Molloy was critical of the clause that would prevent HMOs from changing aspects of contracts without doctor input. Technology is changing all the time, she said. In mid-contract, an HMO may alter a contract to include a new high-tech treatment or to exclude an older, out-of-date treatment. HMOs and insurers need the flexibility to do that. Eliminating it would just add another layer of costs, she said. The medical society is highly critical of insurance firms that retrospectively check billings and demand refunds of overpayments or mistaken payments. The medical society wants their ability to do that restricted, and they want written explanations. The problem with that approach, Molloy said, is that many billers engage in what is called "scatter-shot billing." This results in some providers getting more than one payment for the same treatment. "A fair percentage of them don't refund the extra payment," she said. One of the industry's practices that most infuriates doctors, Ruecker said, is refusing to tell them what they'll be paid for their services. "They tell us they can't give us a list of fees because that's proprietary information," he said. Molloy agreed that fee schedules are guarded jealously. Partly that's to prevent competitors from underbidding an HMO. And partly it's a cost-saving measure. To put it bluntly, if doctors don't know the maximum an HMO or insurer will pay for a procedure, they may bill under that amount, saving the company money. "If they published their fees, doctors who now charge less would immediately up their fees," Molloy explained. And besides, Molloy said, doctors with a little effort can find out an HMO's fees. She said the firms often post notices that their fees range from 100 percent to 120 percent of Medicare fees, which are public. "They can come up with an HMO's fees if they think about it," she said. Molloy pointed out that the costs of regulating HMOs ultimately comes back to their subscribers. "Fifty-eight percent to 85 percent of the cost of health care ultimately comes back to employees in the form of foregone wage increases and loss of other benefits," Molloy said. Saviano said the task force has just about finished taking testimony on the issue. A final report was due in mid-January, but controversy kept legislators and others on the task force going back to square one. Saviano now said he expects a final report to come out sometime in April. Tony Cappasso can be reached at 788-1543 or tony.cappasso@sj-r.com.
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