This has been going on a long time and I have had conversations with doctors here in California who have gone through this procedure with insurers and Aetna as well. In 
one case it was “one” patient who threw the numbers out of whack as they needed special care with a specialist’s specialist with some specific care and treatment that is not the norm but our bodies are not like the one next to us by all means. If you have been around HMOs for any length of time, this is not unusual as that has gone on in California for a long time with one or two patients who need care beyond what is considered “approved” and it happens when patients are extremely sick.
So, what happens when you have one or two patients and as a doctor you fall out of the “averages” for your peers? The video below is from the TMA website where he posted his story and about his attempt to communicate with the CEO of Aetna, which of course did not happen, and at the salary of $8 million a year you might think there could be a little time for a phone call in between appearances at health fairs and conferences trying to win patients over. If you are the one patient who needs expenses covered beyond the “approved” areas you will end up getting your doctor disconnected with the carrier. In addition I have heard where a patient has been treated, recovered and then the insurer comes back and wants the doctor to pay it back! I guess some have not seen this article from January of 2012 about many doctors going broke.
Doctors Going Broke–You Can’t Even Give a Practice Away–Only Folks Buying Them Are Hospitals and Insurance Companies As It Relates to Reimbursement and/or Profits
Aetna and other insurers are also buying up Health IT companies to work with the analytics for reimbursement, so in essence if you consider medical records and billing software they are not only the payer but also the sales folks knocking on the doctor’s door to sell them software too. If you are not within your peer goal numbers, gee they have software to help you…
Subsidiary Watch-Corporate Conglomerate Insurers Reduce Compensation Contracts Using One Subsidiary Then Market Same MDs With Another Subsidiary in Health IT
This doctor and 129 others will no longer be on the Aetna approved list as it’s all about contracts and money. Actually most doctors throughout the US have accepted contracts from insurers that systematically pay them less than what they bill and receive from Medicare…keep that thought if you are a patient. You can though go to Best Buy where they hawk their healthcare software, but if you are really ill that doesn’t cut it.
Best Buy Setting Up to Hawk Software from Aetna For Consumer Wellness–Companies Still Don’t Get the Consumer Involvement Yet With a Vehicle and Creating Value
This actually seems to put the physicians groups (some of which are owned by insurers) in violation of the Medicare “Low Bid” contract that doctors have to accept, to see Medicare patients, and if Medicare had their druthers about this they could possibly go after the insurers and maybe collect some additional funds since Medicare needs money and the insurers/physicians groups are in violation of this clause…interesting thought but has substance for sure. BD
Aetna has notified 130 Texas physicians it will terminate them from its networks on July 1, TMA's Payment Advocacy Department has learned. Aetna says it told the physicians a year ago it was concerned about their billing patterns. Evaluation and management (E&M) codes were the only ones Aetna examined, and its concern involves primarily levels 4 and 5 E&M codes.
Aetna says in letters to the deselected physicians that its data shows their billing and coding practices caused them to be more costly than their peers. TMA secured legal protections in Texas that require Aetna to tell physicians why they are deselected.
TMA has developed a white paper on physicians' basic rights and responsibilities in network terminations. It is not specific to Aetna; any physician deselected by any health plan network can use it.
He says in the video that he is amazed a physician "trying to save lives and help individuals, is controlled by an individual that made $8 million last year. And he’s not a physician. He's directing health care. He's some great entrepreneur that's going to change the world in technology and he doesn’t have time to talk to physicians."
http://www.texmed.org/Template.aspx?id=24069&terms=aetna
Brilliant great story very informative.
ReplyDeleteWhy dont we see all the other doctors backing him up.