DECEMBER 2008

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Help For Medicare Transition
By Jeffrey E. Kaufman, M.D., F.A.C.S., Past-President AACU & CUA, WSAUA Health Policy Cmte.


Two brief issues--one good, the other bad--that occurred recently may be of interest to CUA members.

First, you may well recall that our governor decided last year that billing patients seen in the ER who had HMO insurance with a group you had no contract with was unfair to the patients.  Of course, he ignored the fact that the companies often failed to pay the urologist consultant for his time claiming the care was out of network, unauthorized or unnecessary.  He had no similar concern with fairness to the doctor.  Previously, such responses simply prompted the consultant to "balance bill" the patient directly
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Has this happened to you?

Some of our members report that they are getting a lot of record requests from Anthem and other insurers lately asking for 2 years' records on patients who have procedures. We are told that the insurer is claiming that it is a contractual obligation to provide these records and that the info is being used to cancel the policies of these patients. The review of 2 years' of records is an attempt to mine prior medical care looking for the most minor problem that might not have been fully reflected in their application.  We have heard of other doctors who received these and refused to participate in what was clearly an unethical (if not illegal) activity where the insurer "rescinds" a policy previously provided only after a claim is made. The CUA would like to know if any other members are having these problems.  Anthem and others have already been fined heavily by the state for this.  We believe the CMA should be notified that the activity appears to be ongoing and the state Department of Managed Health Care should be involved. 

Please let us know if this has happened to you. Send us an email or call us at 714-550-9155.

Please report any other concerns or problems that you feel may be widespread so that we can survey our members and take appropriate action.




It's About The Data

By Mark Painter, PRS

Have you ever gone to google and entered your name for a search?  Or just entered Urologist and your city?

Chances are either way you approach a search, among the top returns are going to be physician quality rating sites.   Congress, large corporations and patients are all looking for more for the their health care dollar.  Insurance companies, Medicare, Medicaid and other programs are reacting to the demand
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Urology Practice Management Resources 2008


Useful practice management resources for you and your office management, as presented during the forum on Practice Management WSAUA 2008 
byAmani Abou-Zamzam MBA and Mark Painter, PRS
www.UrologyPracticeConsulting.com



PRACTICE MANAGEMENT AND CODING RESOURCES

-PRSNetwork.com;PrsCoding.com -AUACodingToday.com:

Online coding resource -free to urologists

-UrologyPracticeToday.com:

The best 2 minutes of the Urology
day-free

-CUANet.org:

Up to date coding and practice information

-AUANet.org -WSAUA.org
-AUA/PRS Coding Seminars               -Urology Data Initiative- UDI- PrsNetwork.com
-Electronic Billing-PRSNetwork.com -Practice Management: UrologyPracticeConsulting.com



Chapman Economic Forecast Highlights – What you need to know

By Chris DeSantis, CUA Associate Director, Chapman MBA 1996

Past-President,  Argyros School of Business & Economics Alumni Association – Chapman Univ.


Dear Members,

I wish to share with you highlights of the recent Chapman University Economic Forecast held this past December 9, 2008.  I believe this is relevant to us as we all make important decisions based on our understanding of the fundamentals of our economy. This includes decisions both personal and practice related. We are all impacted by economic trends and having a bit of solid insight can make a big difference... READ MORE...




Western Section AUA Annual Meeting
Oct. 25-29, 2009, J.W. Marriott
Las Vegas, Nevada


Socioeconomic Forum
October 25, 2009, J.W. Marriott
Las Vegas, Nevada


CUA Annual Meeting,
October 27, 2009, J.W. Marriott
Las Vegas, Nevada



California Urological Association
1950 Old Tustin Ave.
Santa Ana, CA 92705
TEL: 714-550-9155
FAX: 714-550-9234
EM:
info@cuanet.org
WEB: www.cuanet.org


NOTE TO MEMBERS: A notice regarding CMA assistance was sent out early this month.  Unfortunately, Michele Kelley's phone number was incorrectly listed. Any members who would like to contact her please use the following updated number. Thank you.

714-634-3908










Help For Medicare Transition
By Jeffrey E. Kaufman, M.D., Past-President AACU & CUA, WSAUA Health Policy Committee

Two brief issues--one good, the other bad--that occurred recently may be of interest to CUA members.

First, you may well recall that our governor decided last year that billing patients seen in the ER who had HMO insurance with a group you had no contract with was unfair to the patients.  Of course, he ignored the fact that the companies often failed to pay the urologist consultant for his time claiming the care was out of network, unauthorized or unnecessary.  He had no similar concern with fairness to the doctor.  Previously, such responses simply prompted the consultant to "balance bill" the patient directly.  Usually, when the HMO company received an irate complaint from their covered patient about a bill he received that the HMO had failed to pay, reimbursement to the doctor was quickly made.  Unfortunately, many patients were caught between the non-paying HMO and the doctor who had provided their care and they complained to the state.  Instead of the state mandating that HMO groups must pay physicians called in to see their patients in the ER fairly and promptly, they decided instead to forbid the doctors from billing the patient at all.  This year, the California Department of Managed Health Care issued a regulation (not legislation) that defined balance billing of patients seen in the ER as "unprofessional conduct" and forbade such activity.  They threatened to turn over any examples to the Medical Board of California for discipline.  However, current law does not give the DMHC such authority over physician billing practices.  Based on this, the CMA challenged this regulation in court. 

As the date arrived to make oral arguments, the DMHC backed off their insistence that such conduct would be prosecuted (acknowledging that they lacked sufficient standing under current law) but maintained that they did in fact have the right to pronounce balance billing "unprofessional conduct".  Unfortunately, while the judge has not officially ruled on their ability to punish such behavior, he has upheld their right to make the pronouncement.  This poses significant challenge to any urologist on call to the ER who sees patients insured by an HMO with whom he does not contract.  He is at the mercy and whim of the payer as to whether he will be paid, how much and when,  Obviously, this also removes any motivation for HMO payers to negotiate fairly with specialists since they know that any unplanned care delivered in the ER will still be paid at the limited rates specified in contracts which the specialist may have already rejected.  This comes about as close to indentured servitude as any action I've seen in quite a while. 

The CMA has plans to appeal this ruling but in the meantime, if you have ER backup responsibilities, you would be well served to limit billing to the HMO insurance company and not balance bill the patient under any circumstances.  I would suggest obtaining legal advice about whether to hold such bills planning to sue for unpaid fees in the future if and after this ruling is overturned.  You might make the patient aware of this potential for future action if you are planning it.  However, under no circumstances should treatment (in the ER or elsewhere) be refused on the basis of economic standing or ability to pay. After all, even while the insurance companies and HMOs are down in the dirt as far as their ethics and business practices, physicians have a moral and ethical duty to provide care even for those unable to pay.  Having said that, I know of no similar moral or ethical responsibility to make insurance companies and HMO groups wealthy at our expense.  We'll see how this plays out in future legal challenges.

On the bright side, a recent court decision overturned a policy that Medicare, for the past several years, has invoked that limits payment for various LHRH agents to what they consider the "least costly alternative."  That means, when two or more agents have similar outcomes, they may pay no more than the cost of the cheapest unless the physician can show good cause that the patient must have the more expensive treatment for bona fide medical reasons.  Even though many doctors have had patients sign Advanced Beneficiary Notices in order to provide and bill for the more expensive agent, this has caused urologists a great deal of difficulty.  Moreover, since payment is now based on Average Sales Price plus 6% (which often doesn't even cover our acquisition costs), the LCA policy is redundant.  A very strong judicial decision was handed down by Judge Henry H. Kennedy Jr. of the Federal District Court of Washington D.C. on October 16 that overturned this LCA policy.  After carefully reading the most recent Medicare law, he concluded that such a policy was not permitted.  Although the ruling was narrowly applied to a drug used for asthma, the principles involved are exactly the same as for LHRH agonists.  At the moment, it is not clear whether CMS plans to appeal the decision but they only have until the middle of December to do so.  Failing an appeal, the judgement stands.  Although it does not constitute case law and therefore is not precedent setting, the reasoning is so clear and forceful that there is no question but that similar challenges are soon to follow.  I personally have asked PPAC (the federal panel advising CMS on implementation of Congressional Medicare law) to question CMS representatives on how and when they plan to adjust other LCA policies but their response is not yet available as of the time this article is written.  While current LHRH agonist costs are too close to each other for this ruling to have an enormous impact, if a new agent comes on line that costs substantially less than currently available agonists but is unable to fill national demand, having had the LCA policy rescinded would be very important. It just goes to show that perseverance pays off.  We can only hope this applies to other disputes with payers and regulators.

Respectfully submitted,

Jeffrey Kaufman M.D., F.A.C.S.
Chair, Health Policy Committee





It's About The Data
By Mark Painter, PRS
 

Have you ever gone to google and entered your name for a search?  Or just entered Urologist and your city?

Chances are either way you approach a search, among the top returns are going to be physician quality rating sites.   Congress, large corporations and patients are all looking for more for the their health care dollar.  Insurance companies, Medicare, Medicaid and other programs are reacting to the demand.

The Physician's Quality Reporting Initiative (PQRI) and Pay for Performance programs are getting more attention.  We hear a number of physicians commenting that the programs are unfair, biased and have nothing to do with Evidence Based Medicine (EBM), the fact that physicians and even payers agree that the data for true EBM is sorely lacking is not stopping the market place reaction.

What can you do?

Of course you have options, here are few to start you thinking, followed by a few recommendations to help you start reacting or at least planning for the future.

1)      DO NOTHING. 

Most physicians are already too busy to worry about adding new processes and procedures to start collecting data related to quality.  Further data analysis and packaging of quality data to prove that you are quality provider will take time away from your patients.  Although we disagree with the bury your head in the sand and wait for something to effect your income approach, there is an argument for doing nothing.  First, there are more patients that will need care in the next few years than providers.  And of course time spent away from providing care costs you money and may not greatly improve patient care right now.


However, if you wish to work less and make more in the future the best method is to change the way you market your services.  Couple this with the shift to more first dollar out of pocket for patients and the fact that Insurers are going to develop and use quality measures that will effect patient flow you may have little choice.  It is our strong belief that the quality argument is just beginning, doing nothing now will cost you later.

2)      PARTICIPATE

Actively submitting codes to PQRI is a good start.  The process to start at this point is relatively easy and although the program has seen its share of problems most are having little trouble getting codes submitted to Medicare.  The payment from Medicare is small for participating but is not the primary reason for playing the game.   A good reason to participate is that Medicare represents the best chance at influencing treatment guidelines at this time.  Finally, if you do not participate Medicare has demonstrated it is not afraid to act without full data or physician support, like it or not quality based pay is coming.


Of course participation is a pain and the pay is too low.  Many are worried that the data is being developed to use against the physicians in the future. 

Another argument against participation is that a lack of data makes it harder to enact protocols.

3)      ANTICIPATE

If you want to get ready for the future start acting now.  Collecting data on your performance and comparing it to your Urology colleagues or even better contributing to a collective database that can be accessed by you without payer control.  Developing and/or following accepted practice standards for each patient with disease protocols in your office will also be marketable and demonstrate concern for patient care.  Practice will also help prepare your office and current programs are non-punitive if you make mistakes. 


Of course the arguments against acting now mirror previous comments of high cost and low return, as well as, a potential risk.


As you can gather we feel strongly that physicians need to prepare for the shift to a quality payment market.   In other words lead, follow or get out of the way.


PRS felt strongly enough about the direction of the marketplace, to develop a tool box that that will allow Urologists to add to a national Urology Dataset and access the data to compare yourself.  The Urology Data Initiative is easy.  It works like a clearinghouse with no disruption to your current office flow.
 




Chapman Economic Forecast Highlights – What you need to know

By Chris DeSantis, CUA Associate Director, Chapman MBA 1996

Past-President,  Argyros School of Business & Economics Alumni Association – Chapman Univ.


Dear Members,

I wish to share with you highlights of the recent Chapman University Economic Forecast held this past December 9, 2008.  I believe this is relevant to us as we all make important decisions based on our understanding of the fundamentals of our economy. This includes decisions both personal and practice related. We are all impacted by economic trends and having a bit of solid insight can make a big difference.

Located in Orange , CA , the Chapman University School of Business and Economics has developed a very accurate forecast model with a proven track record both nationally and statewide. In fact, it was one of only two out of 54 major forecasts to correctly call the current recession and very early on, the crash in housing.

We already know things are bad – but what next?

Office Space – better deals ahead

The first bit of news is that the forecast expects the U.S. office vacancy rate to increase sharply in the next few quarters from 13 to 17 percent. More space is being vacated than leased and new supply is coming online. California is in worse shape with an expected 20% office vacancy rate. If you are looking to buy your own office or renew your lease, you may be in a better bargaining position if you can wait a few months. If you are a landlord, be aggressive in locking in good tenants with a sweet deal.

Home Values – down but not out

Demographic trends and the need for replacement of obsolete housing suggest that demand each year for additional housing will be about 2 million units through 2015. Based on new housing construction in 2007 of 800,000 units, last year produced a housing shortfall of about 1.2 million units. But an excess inventory of vacant rental and single family units now exists to meet that shortfall. However, if we just get back to historical vacancy rates, in 2009 we will use up about 600,000 vacant rentals and 830,000 vacant single-family homes for a total of 1.43 million units. Thus much of the slack inventory will be absorbed in 2009 leading the way for growing demand in 2010. Will that prop up home values? Not likely as the credit squeeze and negative job growth is expected to increase and put downward pressure on home prices. In California , median home prices are forecast to drop by 6.7% in 2009. More expensive homes may see a greater decline.

Other highlights:

  • Expect a short-term rebound in the stock market and economy in the first-half of 2009 as the new economic stimulus package gets underway.  Do not misinterpret this as a change in the fundamentals. It is expected that this will not be sustainable as the recessionary forces currently at work will continue at least through the end of 2009.
  • Healthcare, education, and government spending are the only sectors of economy on the rise.
  • The auto makers' bailout will not solve core problems as this is a case of too little too late.
  • An interesting statistic was presented that proves that the stock market historically goes up every time a Democrat serves as president – on average the S&P 500 goes up 24% during the term of office.
  • The relationship between consumer spending and disposable income will likely change as consumers reduce debt and increase savings. The other factors likely to reduce consumer spending are the negative wealth effect of falling home and stock prices and the consumer credit squeeze.

The economic downturn has a way to go before a recovery takes hold. While some trends will help stabilize the economy later in 2009, such as the impact of lower oil and other commodity prices and the decline in housing vacancies, no major engine of economic growth is on the horizon to lead the economy to expansion.

One final bit of wisdom: Psychology for a time trumps economics as we have seen with the housing bubble, commodities bubble, Internet-stock market bubble, etc. But in the end, economic factors rule.

Chris DeSantis

CUA Associate Director

Chapman MBA 1996 Past-President, Argyros School of Business & Economics Alumni Association
Chapman University
 

 



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