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AETNA to Pay Physicians for Flawed Denials in 1999 & 2000 Attorney General Eliot Spitzer announced an agreement with one of the nation’s largest health plans to improve its referral and claim payment process for the services of medical specialists. The agreement - the first of its kind in New York - resolves complaints from both consumers and physicians that Aetna/US Healthcare had erroneously denied coverage for specialists’ care. Aetna agreed to streamline its referral process and provide both consumers and medical specialists with an opportunity to resubmit claims that may have been denied improperly. Under the terms of the agreement, physicians have until April 30, 2001 to resubmit claims from 1999 and 2000 that were denied due to lack of referrals, or specialists may request from Aetna, a "list of claims denied" for referral-related reasons. Specialists, who request such a list before the April 30, 2001 deadline, will have 60 days from the date they receive the list from Aetna to resubmit claims that were erroneously denied. According to Aetna’s settlement, they will provide a list of denied claims to specialists within 60 days of receipt of the WRITTEN REQUEST made on or before April 30, 2001. The list will include the member’s name, date of service, date of claim receipt by Aetna, date of claim denial and CPT code if any. Physicians must indicate in the letter that an attempt to locate this information within their own records was made and was unsuccessful. Letters should be addressed to: New York Claim
Reconsideration It is strongly recommended that the request be sent Certified Mail -Return Receipt Requested. This agreement is the result of a project created and administered by the Westchester County Medical Society (WCMS) to supply evidence to the Attorney General’s Office verifying detrimental practices being perpetrated by insurance carriers in New York State. The WCMS collected Grievance Factor Log forms in conjunction with eight other county societies including Nassau County Medical Society, and supplied proof of systemic problems with Aetna/US Healthcare’s policies for providing specialist care to their policyholders. Over 2000 insurance grievance forms were collected from physicians’ offices and compiled by the WCMS. The Society was able to supply the Attorney General with hundreds of actual examples in which Aetna had erroneously denied payments to physicians. Consumers and providers with questions or concerns about health care matters may call the Attorney General’s Health Care Hotline at 1-800-771-7755. David Eskreis, MD
A MEDPARD equivalent will be available through the Internet, which will include all participating providers. The directory will be available in mid-February via the Empire web site. You may access this information for the Empire Medicare Services Web at: www.empiremedicare.com.
For the link to the Nassau County MEDPARD page, click here.
The Appellate Court has just affirmed the Supreme Court decision entered by Judge Gangel-Jacob on June 13, 2000, which held that the amendments made to the No-Fault regulations were null and void due to an inadequate Regulatory Impact Statement. The new no-fault regulations shortened the time period of an automobile accident victim to notify the no-fault carrier of an accident from 90 days to 30 days. In addition, the shortened time period for a covered person, or a physician assigned the no-fault benefits, to submit proof of a claim for medical services would be 45 days instead of the original 180 days. By law, the Regulatory Impact Statement was mandatory to ensure that the new no-fault laws were not arbitrary, but protected the right of injured parties to prompt and full compensation. In the appeal of the lower court decision, the Appellate Court rejected the Insurance Department's argument that the Regulatory Impact Statement was sufficient because it only had to consider the impact of that class of "regulated persons," which includes only insurers and self-insurers. Unfortunately, the battle to prevent the new regulations form taking effect is not over. In addition to the appeal of the Supreme Court Decision, the Department of Insurance also issued a new regulation which is identical to the previous regulation with the exception that it includes the required Regulatory Impact Statement. However, until these newly-submitted regulations are declared null and void, car accident victims and physicians should continue to comply with the original 90/180 day time periods for notifying the no-fault carrier.
Legislation has been introduced (S.2269) in the State Senate that would require No-Fault carriers to make payment to a physician or other health care provider who treats the injuries of a person within 48 hours after the injury occurred, despite the fact such person was injured as a result of driving while intoxicated. Current law permits an insurance carrier to disclaim coverage in these instances. The Medical Society supports this legislation because it is unfair to require a physician to render treatment to an injured intoxicated driver who comes to the emergency room, but then essentially prohibit such physician from receiving payment for rendering care. Similar legislation passed the Assembly in 1999 and 2000, but died in the Senate Insurance Committee. This legislation differs from that version in that S.2269 expressly permits the No-Fault carrier to seek recovery from the patient for the cost of the health care services rendered. We will continue to urge appropriate action on this bill.
The Medical Society's fight for passage of the Physician Volunteer legislation (A.534) has seen its first victory with the bill's successful passage out of the Assembly Health Committee. The legislation, one of two bills which encompass the problem, would establish in the Department of Health, a Health Care Practitioner Volunteer Demonstration Program to provide a vehicle for eligible retired health care practitioners to furnish free primary health services to uninsured and indigent individuals. The bill was reported from the Health Committee and referred to the Codes Committee. The second bill in the package (S.284) would exempt physicians serving in this program without compensation from paying registration fees. The Medical Society will continue to fight for passage of these initiatives throughout the 2001 legislative session.
On Tuesday, March 20, MSSNY will hold its Annual State Legislation Day. This is every member's opportunity to meet with their local legislators and discuss issues important to their practice as well as public health. The day consists of a short preparation on legislative issues, lunch with legislators and personal legislative visits. Your legislators really want to know your concerns and personal contact reinforces our legislative efforts in Albany. Many topics of interest to physicians will be discussed in detail including the issues of Volunteer Physician Initiatives and No-Fault payments to physicians who treat intoxicated drivers, as described on this page in detail. Arrangements are underway for transportation to and from Albany on that day. If you are interested in going with the NCMS, please call 516-832-2300 ext 14.
President Clinton and Congress recognized the need for national patient record privacy standards in 1996 when they enacted the Health Insurance Portability and Accountability Act of 1996 (HIPAA). That law gave congress until August, 1999 to pass comprehensive health privacy legislation. After three years of discussion in Congress without passage of such a law, HIPAA provided HHS with the authority to craft such privacy protections by regulation. Following the principles and policies laid out in the recommendations for national health information privacy legislation, the Administration submitted to Congress in 1997, the Administration-drafted regulations to guarantee patients new rights and protections against the misuse or disclosure of their health records and the President released them in October of last year. During an extended comment period, HHS received more than 52,000 communications from the public. This final rule provides the first comprehensive federal protection for the privacy of health information. However, because of the limitations of the HIPAA statute, these protections do not fully achieve the goal of a seamless system of privacy protection for all health information. As required by HIPAA, the final regulation covers health plans, health care clearinghouses, and those health care providers who conduct certain financial and administrative transactions (e.g., electronic billing and funds transfers) electronically. All medical records and other individually identifiable health information held or disclosed by a covered entity in any form, whether communicated electronically, on paper, or orally, is covered by the final regulation. Under this final rule, patients have significant new rights to understand and control how their health information is used. With few exceptions, an individual's health information can be used for health purposes only.
MSSNY recently participated in a roundtable discussion held by the NYS Assembly Insurance committee regarding the issue of No-Fault Fraud and Abuse. Dr. Arthur Wise, Chair of the MSSNY Interspecialty Committee and Past-President of the Nassau County Medical Society, represented MSSNY in this discussion. All groups who participated recognized the impact that fraud has on auto insurance premiums and agreed that greater efforts should be placed on prosecuting illegal activity. However, Dr. Wise and representatives of other provider and consumer groups articulated great concern with legislative and regulatory proposals that could give much greater power to No-Fault carriers to deny legitimate claims brought by accident victims and their health care providers. These measures include Proposed Regulation 68, which would reduce from 90 days to 30 days, the time frame for an accident victim to file a Notice of Claim, and reduce from 180 days to 45 days, the time frame for a health care provider to file proof of medical care. The Appellate Division recently upheld a lower court decision invalidating the regulation, but SID has attempted a re-promulgate (see related article on page 2). The medical society has always been concerned with provisions of this proposal that essentially permit the insurer to be the arbiter of what is a "reasonable" reason for an accident victim or a physician to file a late claim. The Society remains committed to working with both the Legislature and Executive in efforts to identify and prevent insurance fraud. However, the society will continue to work to ensure that payment for legitimate claims should not be sacrificed as a result.
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