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Commercial payers undoubtedly make up some percentage of your patient population. For many practices, issues arising with commercial payers can be extremely cumbersome and time consuming. There are some resources that practices can tap into for assistance and direction.
A practice can contact the state insurance commissioner to file a complaint or discuss problems experienced with private payers. Commissioners may be able to provide answers to general insurance questions, specific information on state regulations, recommendations for a plan of action, or information or follow up on complaints. A listing of state insurance commissioners can be found on the National Association of Insurance Commissioners Web site at http://www.naic.org/state_contacts/sid_websites.jsp.
Communicate any issues you are experiencing with your state medical and specialty societies. These societies may already be aware of complaints that have been filed or provide helpful information on particular issues. Contact information for your state oncology society is available on ASCO's Web site at www.asco.org/stateaffiliates. Contact information for your state medical society can be found on the American Medical Association's (AMA) Web site at http://www.ama-assn.org/ama/pub/category/7630.html.
Another helpful resource is the AMA's Private Sector Advocacy (PSA) unit. The PSA unit was formed in 1998 to advocate on behalf of physicians and help them navigate this complex environment. PSA focuses on exposing and eliminating managed care practices that undermine the physicians' ability to provide quality care to their patients. In addition, the AMA's Advocacy Resource Center (ARC) was created in 1997 to develop model advocacy campaigns on priority state-level issues for use by medical societies and member physicians.
Physicians can let the AMA know about problems they are having with health insurers through the easy-to-use Health Plan Complaint Form. The complaints received are anonymous and confidential, and the information is used to identify trends and to facilitate discussions with national health insurers to resolve the hassles that physicians encounter. It can be accessed through the “HIPAA and Health Plan Complaint Form” link on the PSA Web site at http://www.ama-assn.org/go/psa.
The PSA unit also provides assistance relating to prompt payment issues. The group has created a brochure to highlight and summarize the AMA's efforts to address payment problems. The brochure can be found on the PSA Web site at http://www.ama-assn.org/go/psa by clicking on “Prompt Payment/Payment Hassles.” Currently, 49 states and the District of Columbia have passed prompt payment laws and/or regulations. Additional information about the AMA's Campaign to Promote Timely Payment, including a list of the current state prompt payment laws, can be found on the ARC Web site at: www.ama-assn.org/go/arc through the “Prompt Payment” link.
In addition, PSA has initiated a Managed Care Contracting Campaign that fights against the one-sided contracts physicians typically receive on a take-it-or-leave-it basis, and created a Model Managed Care Contract. According to the AMA, the model contract is an example of what a fair and reasonable managed care contract should look like, and a fourth edition of the AMA Model Managed Care Contract will be available on the PSA Web site in mid-June at http://www.ama-assn.org/go/psa by clicking on “Managed Care Contracting.” It has been updated to reflect new developments in managed care contracting. PSA keeps a watchful eye on health insurers and is quick to challenge any new twists in managed care contracting that create a disadvantage for patients and their physicians.
PSA works hard to combat systematic downcoding and bundling of claims and other unfair payer reimbursement and medical payment policy practices. The group developed the Claims Management Resource Kit, which helps physicians understand and navigate the claims process to assure prompt and full payment for services and procedures provided. PSA has also developed a short checklist, 15 Steps to Protect Your Practice From Abusive Payment Tactics, to help physicians quickly determine how to correct some of these abuses.
Physicians and AMA members can contact PSA at any time by calling 800-464-5000 and asking for Private Sector Advocacy, or by faxing information to 312-464-5541.