Fighting to Level the Playing Field with Managed Care

The efforts of the Health Systems Committee of APMA during these past 12 months have varied—but all of those efforts strive to give our members the strategies and information they can use to adapt to the environment of managed care and to assist our legislative committee in advocating for legislation that helps to level the playing field.

In the November/December issue of the APMA NEWS last year, guidelines were released to assist members with their contract negotiations. It is imperative for each of us to have the ability to evaluate managed care contracts effectively, in order to make intelligent decisions on whether such contracts are in our interest to sign.

Earlier, in April and June 2000, the DPM Managed Care newsletter published valuable information on knowing the value of noncovered services and offered a systematic approach to appealing a denied claim. Both of these articles provided members with important information regarding everyday billing issues.

The Health Systems Committee has been active on the issue of using commercial off-the-shelf software packages. Just as the Correct Coding Initiative (CCI) within Medicare rebundles code combinations, software packages—such as McKesson HBOC’s Claim Check and others—are sold to private insurance companies and managed care plans for rebundling of claims.

These packages are proprietary and thus are not publicly available, as is the CCI from Medicare. The APMA has identified some of the rebundling as inappropriate and is in the process of challenging both individual carriers and the companies that sell the software.

One such inappropriate rebundling is to deny an initial E&M visit on the same day that a minor procedure was performed. APMA feels that it is medically inappropriate for any new patient to have a procedure performed without an appropriate evaluation. APMA also feels that DPMs and all other providers should be compensated for both the initial E&M visit and the minor procedure, when medically necessary, even if both are performed on the same day.

APMA is fighting on multiple fronts to correct these flawed rebundling practices.

The Health Systems Committee, in a two-part series in the May and June 2000 issues of APMA NEWS, released model statutory nondiscrimination legislation language and, in addition, with the help of a consultant, developed a white paper titled “Strategies for Interpreting and Advocating Laws that Prohibit Reimbursement Discrimination Against Podiatrists.”

Through the activities of the Health Systems Committee, APMA was able to convince Independent Health and Humana to accept ABPOPPM certification, as well as ABPS certification, for credentialing DPMs. APMA is attempting to get other insurance companies that accept only one board certification credential, but not the other, to make this type of change.

In addition to pursuing all of these activities, the Health Systems Committee provides advice and recommendations to the Legislative Committee on issues affecting the profession, such as a patients’ bill of rights, prompt-payment laws, the deduction of student loan interest, and collective bargaining.

APMA was pleased that the US Senate passed the health insurance reform bill (S1052). This bill has a nondiscrimination clause that would prevent health plans from differentiating between providers merely by their degree or certification. APMA worked within a coalition of non-MD specialty organizations to include such a provision in every patients’-bill-of-rights legislation introduced into Congress. The provision does not require plans to include every practitioner, but protects practitioners from unfair bias. Other provisions seek to ban gag rules, grant access to medical specialists as needed, and prohibit incentives to reduce care.

As you can see, APMA has had a busy year addressing the needs of private insurance and managed care. We will continue to be the advocate for the profession, and it is important for each of us to work within the APMA on these issues as there is “Strength through Unity.”