Error on Anthem ID cards results in claim denials

California Medical Association
CMA Alert, June 30,2014

In late March, the California Medical Association (CMA) began receiving complaints from physicians in San Diego, Orange and Bay Area counties about denials from Anthem Blue Cross. Practices reported that patients presented to their offices with Anthem ID cards that indicated they had a Covered California/mirror PPO product and subsequent eligibility verification also indicated the patient had a PPO product.

However, Anthem later denied the claims stating the services were not covered under the patients’ benefit plans because they received services from out-of-network providers.

CMA escalated the issue to Anthem and learned that while the Anthem ID card and eligibility verification indicated these patients had purchased PPO products, it was a mistake. These patients had actually purchased EPO products, with no out-of-network benefits.

While Anthem is offering a PPO product for their Covered California/mirror patients in most counties, they are only offering an EPO product in San Francisco, Los Angeles, Orange and San Diego counties. The Anthem EPO product does not provide any benefits if patients receive services from out-of-network physicians/facilities.

At CMA’s urging, Anthem corrected the affected patient ID cards and reissued new cards to EPO patients in May. Anthem also confirmed they have updated the information that displays when physicians verify eligibility to accurately reflect the correct product type.

CMA requested that Anthem automatically reprocess affected claims at the PPO rates, the product the ID card and eligibility information reflected, but Anthem was unwilling to do so. Instead they are requiring patients to appeal each individual claim to Anthem.

http://www.cmanet.org/cma-alert/archives/2014/june-30-2014

Anthem Blue Cross made a mistake in that they provided ID cards and eligibility verification for their EPO (exclusive provider) patients that indicated they were PPO (preferred provider) patients. PPO patients can obtain some care out-of-network but with reduced benefits. EPO patients are not eligible for any benefits out-of-network.

The California Medical Association has requested that Anthem Blue Cross reprocess those claims based on the PPO status that they had verified. Anthem has refused to do so, insisting that each claim be appealed individually. For an industry noted for administrative excesses and placing an administrative burden on health care providers, they are carrying it to an extreme wherein they are requiring much more administrative excesses to rectify their own error – punishing patients and providers for their own mistake.

How can this industry be so crass? Yet this industry, which should be placing patient service above all else, places its own business interests first. Such an insensitive response would never take place if our health care financing system were to be managed by our own public administrators. EPOs wouldn’t even exist. It’s time to replace the private insurers with a publicly-administered single payer system.

UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses evidence-based, medical society, and national industry standards to recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in UnitedHealthcare’s physician directories (e.g., myuhc.com) to support informed decision-making by members when making health care choices and by physicians when making referrals.

Designation information is as follows:

• Quality & Cost Efficiency
• Cost Efficiency & Not Enough Data to Assess Quality
• Quality & Not Enough Data to Assess Cost Efficiency
• Quality & Did Not Meet Cost Efficiency
• Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
• Not Enough Data to Assess
• Not Evaluated
• Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays and co-insurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the following Premium designations:

• Quality & Cost Efficiency
• Cost Efficiency & Not Enough Data to Assess Quality

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____

****

UnitedHealth Premium® Physician Designation Program

Summary Methodology

The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case-mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to evidence-based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician’s designation.

Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality.

Quality Assessment

A physician’s quality individual outcome is determined by comparing the number of times his/her patients received recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician’s observed costs for episodes of care to a peer group’s costs for similar episodes of care, with adjustments for the patient’s severity of illness and the physician’s case mix.

For both episode cost and population cost measurement, the physician’s costs within each set are evaluated against their peer group’s costs by ordering the costs from lowest to highest cost. The costs are converted into percentiles to allow comparison across different types of cases or patients.

Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians (measured in the same specialty for the same types of episodes in the same geographic area) in order to meet the episode cost measurement criteria.

UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Assets/ProviderStaticFiles/ProviderStaticFilesPdf/Unitedhealth%20Premium/UnitedHealth_Premium_Summary_Methodology_2013-2014.pdf

****

Comment:

By Don McCanne, MD

The perennial promise of private health insurers is that their insurance products would bring us higher quality care at lower cost, even though there is a paucity of evidence to support such claims. UnitedHealth now claims to be serious about delivering on that promise with their new Premium Physician Designation Program. They say that “quality is the fundamental measurement.” But let’s sort through their program description to see what the truth really is.

You can consult the websites at the links above for the detailed descriptions of how determinations of quality and cost efficiency are made. Although they state that quality is the fundamental measurement, they combine that with cost efficiency measurements and then use this information to classify each physician in one of the eight categories listed above. There are really only two designations that physicians can receive: quality and cost efficiency. If the physician receives either one or both of these designations, then these honors are displayed publicly in UnitedHealth’s physician directories.

Those designations might be nice, but what the patient really wants to know is if their physician is a Tier 1 physician. In plans that offer tiered benefits – very commonplace today – plan beneficiaries pay lower co-pays and co-insurance when they use Premium Tier 1 physicians. So what determines whether on not a physician is in Tier 1?

Of the eight categories listed, only the first two will qualify the physician as Tier 1. Either the physician must receive the designations of “Quality & Cost Efficiency” or “Cost Efficiency & Not Enough Data to Assess Quality.” Although quality is the “fundamental measurement” and is determined before cost efficiency, it is important to note that the third category – “Quality & Not Enough Data to Assess Cost Efficiency” – will not qualify a physician for Tier 1. The only way to become a Tier 1 physician is to be cost efficient; quality does not count.

It is also important to understand that even if all or almost all physicians are actually cost efficient, they are compared to their peers. “Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians.” It is impossible, no matter how efficient they are, for all physicians to gain Tier 1 status.

Further, the health care market in the United States is by far the most expensive of all nations, not only because of our prices but also due to our inefficiencies, especially our profound administrative waste. Favoring prices at the lower end of a highly inflated health care market falls far short of what we need to do to improve efficiency in our health care purchasing.

Thus UnitedHealth, for Tier 1, is selecting the cheapest physicians in an overpriced and inefficient market, regardless of the quality of their care. “Higher quality at lower cost” is a fraudulent marketing slogan of the private insurance industry. We need to throw these con artists out and replace them with our own efficient, quality-driven single payer national health program. The sooner the better.

UnitedHealth Premium® Designation Program

The UnitedHealth Premium® physician designation program uses evidence-based, medical society, and national industry standards to recognize physicians for providing quality and cost efficient care.

The following designation results are displayed publicly in UnitedHealthcare’s physician directories (e.g., myuhc.com) to support informed decision-making by members when making health care choices and by physicians when making referrals.

Designation information is as follows:

• Quality & Cost Efficiency
• Cost Efficiency & Not Enough Data to Assess Quality
• Quality & Not Enough Data to Assess Cost Efficiency
• Quality & Did Not Meet Cost Efficiency
• Not Enough Data to Assess Quality & Did Not Meet Cost Efficiency
• Not Enough Data to Assess
• Not Evaluated
• Did Not Meet Quality & Cost Efficiency

Innovative Benefit Plan Designs

In addition, employers may offer health benefit programs (e.g., reduced cost-sharing or tiered benefit programs) that provide benefit incentives for members to use UnitedHealth Premium Tier 1 physicians.

Members in health plans that offer tiered benefits may pay lower co-pays and co-insurance amounts for services provided by UnitedHealth Premium Tier 1 physicians.

UnitedHealth Premium Tier 1 physicians have received one of the following Premium designations:

• Quality & Cost Efficiency
• Cost Efficiency & Not Enough Data to Assess Quality

https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b046…

****

UnitedHealth Premium® Physician Designation Program

Summary Methodology

The UnitedHealth Premium physician designation program uses clinical information from health care claims and other sources to assist physicians in their continuous practice improvement and to help consumers make more informed and personally appropriate choices for their medical care.

Evaluation for quality compares a physician’s observed practice to the UnitedHealthcare national rate among other physicians who are responsible for the same interventions. Cost efficiency is assessed by comparing the case-mix adjusted cost of care attributed to the physician to a benchmark and applying a statistical test to determine if the difference is statistically significant.

Quality is the fundamental measurement, demonstrating our commitment to evidence-based practice. The quality designation is separate from the cost efficiency designation. Although the quality and cost efficiency evaluations are performed separately, the results are used together to determine the physician’s designation.

Physicians who meet both the quality and cost efficiency designation criteria will receive the quality and cost efficiency designation. Physicians who meet the quality designation criteria will receive the quality designation regardless of their cost efficiency evaluation. Physicians who meet the cost efficiency designation criteria will receive the cost efficiency designation if they do not have enough data to assess quality.

Quality Assessment

A physician’s quality individual outcome is determined by comparing the number of times his/her patients received recommended care with a benchmark number based on the UnitedHealthcare national rate of the same recommended care for each quality measure.

Cost Efficiency Assessment

Episode cost measurement compares a physician’s observed costs for episodes of care to a peer group’s costs for similar episodes of care, with adjustments for the patient’s severity of illness and the physician’s case mix.

For both episode cost and population cost measurement, the physician’s costs within each set are evaluated against their peer group’s costs by ordering the costs from lowest to highest cost. The costs are converted into percentiles to allow comparison across different types of cases or patients.

Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians (measured in the same specialty for the same types of episodes in the same geographic area) in order to meet the episode cost measurement criteria.

UnitedHealthcare informs members that designations are intended only as a guide when choosing a physician and should not be the sole factor in selecting a physician. As with all programs that evaluate performance based on analysis of a sample, there is a risk of error.

https://www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/A…

The perennial promise of private health insurers is that their insurance products would bring us higher quality care at lower cost, even though there is a paucity of evidence to support such claims. UnitedHealth now claims to be serious about delivering on that promise with their new Premium Physician Designation Program. They say that “quality is the fundamental measurement.” But let’s sort through their program description to see what the truth really is.

You can consult the websites at the links above for the detailed descriptions of how determinations of quality and cost efficiency are made. Although they state that quality is the fundamental measurement, they combine that with cost efficiency measurements and then use this information to classify each physician in one of the eight categories listed above. There are really only two designations that physicians can receive: quality and cost efficiency. If the physician receives either one or both of these designations, then these honors are displayed publicly in UnitedHealth’s physician directories.

Those designations might be nice, but what the patient really wants to know is if their physician is a Tier 1 physician. In plans that offer tiered benefits – very commonplace today – plan beneficiaries pay lower co-pays and co-insurance when they use Premium Tier 1 physicians. So what determines whether on not a physician is in Tier 1?

Of the eight categories listed, only the first two will qualify the physician as Tier 1. Either the physician must receive the designations of “Quality & Cost Efficiency” or “Cost Efficiency & Not Enough Data to Assess Quality.” Although quality is the “fundamental measurement” and is determined before cost efficiency, it is important to note that the third category – “Quality & Not Enough Data to Assess Cost Efficiency” – will not qualify a physician for Tier 1. The only way to become a Tier 1 physician is to be cost efficient; quality does not count.

It is also important to understand that even if all or almost all physicians are actually cost efficient, they are compared to their peers. “Physicians’ costs must be statistically significantly lower than the peer group’s physicians at the 75th percentile performance for all physicians.” It is impossible, no matter how efficient they are, for all physicians to gain Tier 1 status.

Further, the health care market in the United States is by far the most expensive of all nations, not only because of our prices but also due to our inefficiencies, especially our profound administrative waste. Favoring prices at the lower end of a highly inflated health care market falls far short of what we need to do to improve efficiency in our health care purchasing.

Thus UnitedHealth, for Tier 1, is selecting the cheapest physicians in an overpriced and inefficient market, regardless of the quality of their care. “Higher quality at lower cost” is a fraudulent marketing slogan of the private insurance industry. We need to throw these con artists out and replace them with our own efficient, quality-driven single payer national health program. The sooner the better.

Opinion of the Court

Supreme Court of the United States, June 30, 2014

BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL.

and

CONESTOGA WOOD SPECIALTIES CORPORATION ET AL., PETITIONERS 13–356 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.

Justice Alito delivered the opinion of the Court.

We must decide in these cases whether the Religious Freedom Restoration Act of 1993 (RFRA), 107 Stat. 1488, 42 U. S. C. §2000bb et seq., permits the United States Department of Health and Human Services (HHS) to demand that three closely held corporations provide health-insurance coverage for methods of contraception that violate the sincerely held religious beliefs of the companies’ owners.

In holding that the HHS mandate is unlawful, we reject HHS’s argument that the owners of the companies forfeited all RFRA protection when they decided to organize their businesses as corporations rather than sole proprietorships or general partnerships. The plain terms of RFRA make it perfectly clear that Congress did not discriminate in this way against men and women who wish to run their businesses as for-profit corporations in the manner required by their religious beliefs.

Since RFRA applies in these cases, we must decide whether the challenged HHS regulations substantially burden the exercise of religion, and we hold that they do.

****

Ginsburg, J., dissenting

Importantly, the decisions whether to claim benefits under the plans are made not by Hobby Lobby or Conestoga, but by the covered employees and dependents, in consultation with their health care providers. Should an employee of Hobby Lobby or Conestoga share the religious beliefs of the Greens and Hahns, she is of course under no compulsion to use the contraceptives in question. But “[n]o individual decision by an employee and her physician — be it to use contraception, treat an infection, or have a hip replaced — is in any meaningful sense [her employer’s] decision or action.” Grote v. Sebelius, 708 F. 3d 850, 865 (CA7 2013) (Rovner, J., dissenting). It is doubtful that Congress, when it specified that burdens must be “substantia[l],” had in mind a linkage thus interrupted by independent decisionmakers (the woman and her health counselor) standing between the challenged government action and the religious exercise claimed to be infringed. Any decision to use contraceptives made by a woman covered under Hobby Lobby’s or Conestoga’s plan will not be propelled by the Government, it will be the woman’s autonomous choice, informed by the physician she consults.

http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf

****

Comment:

By Don McCanne, MD

Allowing an employer to deny coverage of family planning services for employees, strictly on the basis of the employer’s own religion, is yet one more flaw in our highly dysfunctional system of health care financing – a system that is being perpetuated by the Affordable Care Act. If we had a single payer national health program, the employer would not be involved.

As Justice Ginsburg stated in her dissent, a woman’s use of family planning services should be “the woman’s autonomous choice, informed by the physician she consults.” If religious beliefs enter into that decision, it should be the religious beliefs of the individual and not anyone else.

Opinion of the Court

Supreme Court of the United States, June 30, 2014

BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL. v. HOBBY LOBBY STORES, INC., ET AL.

and

CONESTOGA WOOD SPECIALTIES CORPORATION ET AL., PETITIONERS 13–356 v. SYLVIA BURWELL, SECRETARY OF HEALTH AND HUMAN SERVICES, ET AL.

Justice Alito delivered the opinion of the Court.

We must decide in these cases whether the Religious Freedom Restoration Act of 1993 (RFRA), 107 Stat. 1488, 42 U. S. C. §2000bb et seq., permits the United States Department of Health and Human Services (HHS) to demand that three closely held corporations provide health-insurance coverage for methods of contraception that violate the sincerely held religious beliefs of the companies’ owners.

In holding that the HHS mandate is unlawful, we reject HHS’s argument that the owners of the companies forfeited all RFRA protection when they decided to organize their businesses as corporations rather than sole proprietorships or general partnerships. The plain terms of RFRA make it perfectly clear that Congress did not discriminate in this way against men and women who wish to run their businesses as for-profit corporations in the manner required by their religious beliefs.

Since RFRA applies in these cases, we must decide whether the challenged HHS regulations substantially burden the exercise of religion, and we hold that they do.

****

Ginsburg, J., dissenting

Importantly, the decisions whether to claim benefits under the plans are made not by Hobby Lobby or Conestoga, but by the covered employees and dependents, in consultation with their health care providers. Should an employee of Hobby Lobby or Conestoga share the religious beliefs of the Greens and Hahns, she is of course under no compulsion to use the contraceptives in question. But “[n]o individual decision by an employee and her physician — be it to use contraception, treat an infection, or have a hip replaced — is in any meaningful sense [her employer’s] decision or action.” Grote v. Sebelius, 708 F. 3d 850, 865 (CA7 2013) (Rovner, J., dissenting). It is doubtful that Congress, when it specified that burdens must be “substantia[l],” had in mind a linkage thus interrupted by independent decisionmakers (the woman and her health counselor) standing between the challenged government action and the religious exercise claimed to be infringed. Any decision to use contraceptives made by a woman covered under Hobby Lobby’s or Conestoga’s plan will not be propelled by the Government, it will be the woman’s autonomous choice, informed by the physician she consults.

http://www.supremecourt.gov/opinions/13pdf/13-354_olp1.pdf

Allowing an employer to deny coverage of family planning services for employees, strictly on the basis of the employer’s own religion, is yet one more flaw in our highly dysfunctional system of health care financing – a system that is being perpetuated by the Affordable Care Act. If we had a single payer national health program, the employer would not be involved.

As Justice Ginsburg stated in her dissent, a woman’s use of family planning services should be “the woman’s autonomous choice, informed by the physician she consults.” If religious beliefs enter into that decision, it should be the religious beliefs of the individual and not anyone else.

Department of Health and Human Services, June 19, 2014

This proposed rule would specify additional options for annual eligibility redeterminations and renewal and re-enrollment notice requirements for qualified health plans offered through the Exchange, beginning with annual redeterminations for coverage for plan year 2015.

In paragraph (j)(1), we propose that if an enrollee remains eligible for enrollment in a QHP through the Exchange upon annual redetermination, and the product under which the QHP in which he or she was enrolled remains available for renewal, consistent with 45 CFR §147.106, such enrollee will have his or her enrollment in a QHP under the product renewed unless he or she terminates coverage, including termination of coverage in connection with voluntarily selecting a different QHP, in accordance with §155.430. In this situation, we propose that the QHP in which the enrollee will be renewed will be selected according to the following order of priority: first, in the same plan as the enrollee’s current QHP, unless the current QHP is not available; second, if the enrollee’s current QHP is not available, the enrollee’s coverage will be renewed in a plan at the same metal level as the enrollee’s current QHP; third, if the enrollee’s current QHP is not available and the enrollee’s product no longer includes a plan at the same metal level as the enrollee’s current QHP, the enrollee’s coverage will be renewed in a plan that is one metal level higher or lower than the enrollee’s current QHP; and fourth, if the enrollee’s current QHP is not available and the enrollee’s product no longer includes a plan that is at the same metal level as, or one metal level higher or lower than the enrollee’s current QHP, the enrollee’s coverage will be renewed in any other plan offered under the product in which the enrollee’s current QHP is offered in which the enrollee is eligible to enroll.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/508_CMS-9941-P-OFRv-6-26-14.pdf

****

Exchange Plan Renewals: Many Consumers Face Sizeable Premium Increases in 2015 Unless They Switch Plans

By Elizabeth Carpenter
Avalere, June 26, 2014

Under the Affordable Care Act, federal premium assistance is tied to the second lowest cost silver plan (“benchmark plan”) in a given region.  Subsidized exchange enrollees who select a more expensive plan must pay the difference—dollar for dollar—between the benchmark plan premium and their selection.  In six of nine states analyzed by Avalere, the 2014 benchmark silver plan will lose benchmark status in 2015. Further, in seven of the nine states, the lowest cost silver plan will also change in 2015. 

“Most enrollees in 2014 chose a plan based on the monthly premium. However, the lowest cost plans in 2014 may no longer be low cost in 2015,” said Elizabeth Carpenter, director at Avalere Health. “Before consumers renew their 2014 plan, they should consider the tradeoff between continuity of care and lower monthly premiums.”

“Two-thirds of people enrolling in silver plans are choosing one of the two lowest cost silver options,” said Caroline Pearson, vice president at Avalere. “The competitive landscape for plans is changing in 2015. However, the premium subsidies are tied to the benchmark plan and a percentage of income. Consumers have to pay the difference if they enroll in a plan more expensive than the benchmark.  Those receiving federal premium subsidies may need to switch plans in 2015 to avoid paying more than the limits established by the ACA, and the impact will be more profound for lower-income consumers.”

http://www.avalerehealth.net/expertise/managed-care/insights/exchange-plan-renewals-many-consumers-face-sizeable-premium-increases-in-20

****

Comment:

By Don McCanne, MD

Acknowledging the complexity of the administration of the exchanges under the Affordable Care Act, HHS has decided to simplify the process by making renewal of plan enrollment automatic unless the enrollee decides on a different option. It is estimated that about 95 percent of enrollees will qualify for automatic renewal, and undoubtedly many will passively accept this hassle-free option. That may not be a wise choice.

The Avalere report indicates that the benchmark silver tier plan – the plan with the second lowest premium in the silver tier – will change in many of the exchanges since premium bids are changing for most plans. Since the enrollee is responsible for the full balance of the premium above the benchmark plan, net premiums for the enrollees could increase significantly unless the person opted to change to next year’s benchmark plan or a plan close to it.

As Avalere director Elizabeth Carpenter states, “(consumers) should consider the tradeoff between continuity of care and lower monthly premiums.” This means that those current enrollees who do not passively accept higher premiums will be forced to choose between higher premiums or a change in their narrow provider networks, the latter likely resulting in disruption of continuity of care.

Further, according to the HHS rule, the individual could be transferred to a different metal tier, thereby losing eligibility for the subsidies for cost sharing, though that would likely occur only in exchanges that have few choices.

Even something as simple as “automatic renewal” becomes complex when you try to rely on market dynamics to satisfy private insurers. Imagine if at renewal time you didn’t have to make a decision on what premiums you could afford, or on what provider networks you would choose when none of them quite fit, or where you might fall based on subsidy eligibility redetermination.

Imagine instead if the concept of renewal did not even exist – you were simply automatically enrolled for life. We really do need to replace this boondoggle with a single payer national health program – quality health care for everyone at a price we can afford.