AAFP Department of Private Sector Advocacy provides tools and support for members

By Kate McCann

When a letter arrived in the mail on Valentine’s Day 2004, the white business envelope looked just like any other that routinely passed through the mailbox of Earl Carstensen, M.D. The content of the registered letter, however, is what would strike the Colorado family physician “like a shot in the gut.” The letter, from a representative at a large medical insurance company, informed him that a routine chart review revealed practice patterns containing an above-average amount of 99214 and 99215 codes and that he was subject for review. To him, the letter was one directed to frighten and intimidate.

Carstensen felt it necessary to stand up for his practice, but was unsure of where to start in the fight against a company from which he drew 35-40 percent of his practice income. He started talking to representatives from the Colorado Medical Association, the Colorado Academy of Family Physicians and fellow physicians on AAFP’s practice management listserv. On the listserv he found many sympathizers who started a collaboration that would help him respond to the company. They, in turn, helped raise awareness within the national Academy to inspire new ways to increase support for private sector physicians.

The movement began as several groups from within and outside of AAFP worked to identify the common concerns of small-practice physicians and strengthen the voice of primary care in the health care system. In October 2005, the AAFP Board of Directors adopted a private sector advocacy work plan that served as a road map for private sector advocacy activities and led to the development of one of AAFP’s largest contributions to the effort, the Department of Private Sector Advocacy. The department’s work is most apparent on the private sector advocacy page of AAFP’s Web site, www.aafp.org. Here, AAFP members can access online tools, resources, e-mail listservs and policy statements for many different issues.

The listserv for private sector advocacy, which grew from the practice management listserv, supports open dialogue between members on a private e-mail discussion forum. AAFP members who subscribe to the listserv can send and review e-mails and post information on the bulletin board, which consolidates comments by topic and allows users to access specific conversations about each issue. AAFP staff members monitor the discussions to gain insight into what topics physicians consider the most important to their practices. From there, the staff can align advocacy efforts appropriately and post resources on the bulletin board for informational purposes.

Shirley Pigott, M.D., of Victoria, Texas, credits AAFP for hosting the listservs, identifying the medium for physicians to tell stories, throw around ideas and coordinate action as helpful. “It’s a risky thing to host a forum where you are just as likely to get jumped on as not,” she says. “Someone in AAFP took a big risk.”

The online Health Plan Complaint Form is another tool offered by AAFP. Members can log complaints regarding health plan interactions or view the complaints of others. On it, members have traditionally been directed to a similar form provided by the American Medical Association, but a desire to own the data and use it more effectively led to the establishment of AAFP’s own. The complaints reside on the members-only Web site that offers a secure forum to discuss health plan concerns. A searchable database of complaints organized by date, issue or health plan will launch later this summer.

Academy staff members like Trevor Stone, a private sector advocacy specialist in the department, hope that the collaboration between member physicians will empower them to submit complaints in a trusted environment.

“From the grass roots, members feel like they have a voice,” Stone says. “They can increase their knowledge to feel more informed and work together to find solutions.”

Though the complaint form is not a proxy for the Academy to address each case, members who need assistance can access appropriate resources or policy statements, Stone says. Academy representatives use the complaints in meetings with health plans, specialty societies, employers and other private sector entities. These meetings are meant to help AAFP build and maintain relationships with these groups.

“Academy leaders now hear us, understand us and validate what we’re saying and what our concerns are,” Carstensen says. “Actions are being taken and we’re in a much better place [than two years ago].”

Increased demand on the Department on Private Sector Advocacy prompted AAFP to add an additional specialist to the team with an insider’s perspective. Laura Schmidt comes from the managed care arena, having worked in insurance company operations, contracting and pricing for both insured and self-funded products, according to an AAFP special bulletin.

The official launch of AAFP’s Department of Private Sector Advocacy focused many previous years of work. Though several projects and resources are still in development, the staff continuously works to address the concerns of all private sector physicians and looks to place more emphasis on influencing positive change for this group.

Making the “smart” choice

Denison 5th grader wins Texas Tar Wars Poster Contest

TAFP congratulates this year’s Texas Tar Wars Poster Contest winner, Sanjida Hoque of Denison, Texas. Hoque’s poster, “If you don’t ever start, you prove you’re smart,” was selected for the grand prize from among many entries by a select panel of TAFP members. Her message reinforces the anti-smoking mission supported by the Texas Department of Health and the Academy.

Hoque is in Mr. Kris Ackerman’s fifth grade class at Sam Houston Elementary School in Denison. She is the daughter of Sarwarul Hoque.

Deadline to apply for National Provider Identifier draws near

By May 23, 2007, all health care providers need to have and use a National Provider Identifier on standard health care transactions specified by the Health Insurance Portability and Accountability Act of 1996. The NPI, a 10-digit, numeric identifier assigned by the Centers for Medicare and Medicaid Services, is part of the effort to ameliorate medical claims processing and payment issues.

HIPAA mandates instituted the NPI to give individual health care providers a unique identifying number and eliminate the need for physicians to provide different identifying numbers for each health plan claim.

Physicians can obtain an NPI in one of three ways:

• Apply at https://NPPES.cms.hhs.gov;
• Call the NPI Enumerator at (800) 465-3203 and request a paper NPI application form; complete and mail it back to the address on the form; or
• Apply for a bulk enumeration, which allows an Electronic File Interchange Organization approved by CMS to obtain a number of providers’ NPIs.

Additional background is available in the Regulations and Guidance section of the CMS Web site, www.cms.hhs.gov, under HIPAA Administrative Simplification.

Retail health clinics to open in Dallas

By the end of the summer, a new retail health clinic chain will open clinics in the Dallas-Fort Worth Metroplex. MedXpress, founded by Dallas brothers Brian and Stephen Jones, will open five clinics by the end of 2006 and 25 more within the next three years in Minyard Food Stores, according to a company press release. Minyard Food Stores, Inc. operates 67 supermarkets and 15 fuel stations under the Minyard, Carnival and Sack’n Save banners throughout the Dallas-Fort Worth area. The first MedXpress clinic will be located in the new Carnival flagship store in southwest Dallas’ Oak Cliff area.

The appeal of the clinics as an alternative to emergency, urgent or primary care is growing. They first appeared in Texas when HEB and retail health clinic partner, RediClinic, teamed up to open locations in Austin, San Antonio and Houston. The clinics are staffed by nurse practitioners or physicians’ assistants and generally require a physician to be on-call or on-site and to review a percentage of patient charts. Since the clinics do not process insurance claims, all patients pay a flat fee of around $45. For the fee, patients can choose from a menu of services including physical exams, immunizations and treatment of common illnesses such as allergies, bladder infections, bronchitis, ear and sinus infections and strep throat. Most appointments last 15 minutes.

RediClinic President and CEO, Web Golinkin, has also announced plans to open Dallas locations within a year in the previously untouched market, according to an article in the Dallas Business Journal. The company projects to open 500 clinics across the country by 2009.

Higher spending doesn’t equate to higher quality, study finds

The country could save as much as 30 percent on Medicare spending while providing better care by changing the way patients with severe chronic illnesses are treated, according to a recent study by the Dartmouth Atlas Project. Researchers found that states relying more on primary care rather than specialty care for the treatment of patients suffering from chronic illnesses had lower health care spending and better quality outcomes. The extra spending, resources, physician visits, hospitalizations and diagnostic tests in high-spending states did not buy longer life or better quality of life for patients, the study reported.

In “The Care of Patients with Severe Chronic Illnesses: A Report on the Medicare Program,” published by Dartmouth Medical School Center for the Evaluative Clinical Sciences, the study’s authors challenged the medical community to re-evaluate its use of resources and to examine the treatment methods of the most efficient providers to reduce spending, specifically in public health care programs.

The authors suggest that to fix high health care spending, shifting resources from the acute care sector to a community-wide integrated system for managing severe chronic illnesses should be the nation’s goal. This system would maximize efficiency and minimize utilization by acute care providers while upholding a high standard of care that meets the needs of the patients.

This study reinforces findings in another Dartmouth study published in the March/April 2004 edition of Health Affairs, “Medicare Spending, The Physician Workforce, and Beneficiaries’ Quality of Care.” That study shows that states with a higher concentration of specialists than primary care physicians account for more Medicare spending and have higher rates of morbidity and mortality.

Modifier mix-up reconciled

Physicians to recoup claims denials from Aetna

Thanks to an effective mediation process, Aetna, an insurance plan that contracts with many FPs, has agreed to rectify a payment dispute dating back to July 2004. Aetna’s action stands to benefit not just the physicians directly involved in the dispute — but all physicians who do business with the insurer.

For nearly two years, physicians who billed for an evaluation and management visit and a procedure on the same day — and correctly appended the E/M code with the modifier -25 — were routinely denied payment for the procedure portion of the visit. Apparently, a mix-up in the appropriate use of modifiers caused the disagreement; Aetna wanted such claims appended with the modifier -59.

The mediation in the dispute was one of the terms of a settlement agreement reached in May 2003 between some of the nation’s largest health plans, including Aetna, and more than 800,000 physicians and state and county medical associations. The class action lawsuit alleged that the health plans violated federal civil racketeering laws by scheming to deny payments to physicians.

As part of the mediated solution, Aetna will automatically reprocess previously denied claims that date back to July 1, 2004. Physicians who filed compliance disputes on the modifier -25 issue will have their claims reworked dating back to May 21, 2003, the date of the class settlement, according to Cynthia Michener, Aetna’s public relations manager.

Physicians do not need to take any action. Details of the agreement, along with a complete list of the more than 200 affected procedure codes, are posted on Aetna’s Web site.

“This is a big deal. Physicians whose services were denied will be reimbursed accordingly without need for resubmission of claims,” says Cynthia Hughes, AAFP’s coding and compliance specialist.

“The list includes procedures common to an FP’s practice, such as venipuncture, arterial puncture, inhalation treatments and electrocardiograms. The fact that Aetna will automatically reprocess these (claims) means that physicians may recover what was written off in error,” says Hughes.

As a permanent solution, Aetna is updating its claims processing system to reimburse certain specific procedure codes when billed with an E/M code appended by the modifier -25, said Michener. However, to expedite payment on new claims until system changes are complete, physicians may append the modifier -59 to the minor procedure codes listed on Aetna’s Web site and billed with an E/M code.

According to a notice on Aetna’s Web site, physicians who prefer to use the modifier -25 during the interim period will receive payment, but processing of those claims may take longer.

Michener cautioned that until Aetna’s information technology system corrections are completed late in 2006, “providers may continue to receive payment denial notices that have been automatically generated by our claim system.” She says physicians should disregard these notices. “No action is needed on their part. Aetna will periodically run reports to capture these claims and will then manually reprocess for payment,” she says.

Source: AAFP News Now, June 6, 2006. © 2006 American Academy of Family Physicians.

Internet scam targets ABMS diplomats

The American Board of Medical Specialties issued an alert in April to warn member boards of an Internet marketing campaign and practice that targets diplomates of ABMS. The false certification Web site, BoardCertified.com, sends fax messages to physicians with ABMS identifiers claiming to be “renewal notices.” The messages state that physicians failing to complete the faxed form and pay the renewal fee to BoardCertified.com by a certain date will face an expired “membership” and a deactivated “online listing.”

In an issued alert, ABMS states that BoardCertified.com is not a legitimate user of ABMS’ name, acronyms, trademarks, logos, intellectual property or certification data. The alert clarifies that failure to return the form or fee to BoardCertified.com will not result in any penalty, expiration of certification or removal from ABMS’ official online directory, BoardCertifiedDocs.com, published by Elsevier, as the Web site warns. ABMS and the American Medical Association, whose trademarked name and acronym also appear on the site without permission, are evaluating the activities of BoardCertified.com and pursuing aggressive legal action. The ABMS staff assures members that the legitimate online database remains secure and protected.

If you have received a message from BoardCertified.com or if you have additional questions about BoardCertified.com’s apparent misues of ABMS’ intellectual property, contact Rob Nelson at ABMS by phone at (847) 491-9091, ext. 3005, or by e-mail at rnelson@abms.org.