Re: FW: Unethical tactics by MCOs- RESPONSES
Jim DeWees
Description
Collection
Title:
Re: FW: Unethical tactics by MCOs- RESPONSES
Creator:
Jim DeWees
Date:
4/20/2006
Text:
Dear list members,
I have been thinking about what to post or how to respond to this issue. I
have had very similar issues here in the midwest, the worst one was about 6
months ago. A large insurance company no longer does its own contracting,
and has another company that does all the ancillary management for them.
So, all of the sudden my contract with the insurance company was no longer
any good, and I had to redo the contract now through the other company. I
was told that the pricing would not change, it was just the process that was
changing. I asked them for a list of codes with dollar amounts on it, and
they provided it to me. It was HORRIBLE. The pricing was incredibly
different. The L-5981 (Flex Foot of equal) was only paying $1350, which
does not even come close to covering the cost of a Modular III foot. The
silicone liners were only being paid at $165, which is well below the cost
of most liners. All the codes were about the same as these, very much below
medicare and medicaid. I had to decline on the contract, telling them that
I would loose money on every single prosthesis that I would make for them.
It was not a matter of not making enough money to make it worth my time, but
it was just that the cost of the components and materials cost more than
what they were paying me.
So after a few very bad conversations with them, and also having a very
vocal patient that works for a large school system that uses this insurance
get involved, things started to change. First off, I had the patient go to
the school board, explain that because of the very poor pricing of this
certain insurance company, he was requesting the school system look for a
different insurance company that would actually let the employees have
access to better doctors and health care providers. He showed the board a
few examples of what medicaid pays to providers, and what this insurance
company was paying for the same procedure codes. His final statement was
that it is a sad day when a person that has no job, no money, no insurance
(except for medicaid which is for the poor or disabled) has better coverage
than what a school teacher, or anyone else that might have this insurance.
So, the school board chose to change to a different insurance company.
This got the attention of the insurance company, they don't like it when
they lose the contracts of their paying customers.
Also, at this time we had a meeting in the area where many of the
practitioners were attending, and I talked with them casually about this
issue, knowing very well that we cannot discuss too much about anything like
this, but we can talk. We were all in the same boat. But, there was one
that sold us all out.
When I talked with another person at this insurance company, I told them I
was also an amputee, a member of the ACA, and that I could do my best to
influence all other practitioners and facilities to not sign on with them,
and if they have no providers in this area, then they are open to a class
action law suit from the insured because there are no providers. They are
required to have providers for the insured, and they know that. In fact,
many of us in this area did not sign on, and I think they must have started
to worry a little. Shortly after all this, I got an email with a NEW price
sheet attached. They prices went up a little bit, but still not even close
to the old figures before the change took place. I still told them no.
Then the next day I got another email, with different prices, but still
insulting. I said no to that one also. Finally, I got an email that
afternoon, which the pricing the same as the old numbers, (which is better
than Anthem, but that is not saying much).
In the email, the slimy salesman used the tactic that he was able to get MY
prices back to the same as what they used to be, which is a lot higher than
any other provider in this region. In fact, I was the ONLY person that he
was able to make this deal for. And, I had until that afternoon to either
take it or leave it. I told him that was a very insulting way to do
business, it was worse than going and buying a used car...Have I got a deal
for you, if you buy it now...
The other thing that was discussed, when I told him that as a member of the
ACA I would do everything to influence the prosthetists here to not sign
with them, he told me that did not matter to him. They are always protected
from that. They have a nationwide contract with a major company (I think we
all know who that would be), so they do have a provider in this area, and
they are contracted at the lower prices, that is what they signed on right
at the very beginning.
Again, how many times have we seen our very own people in this field sell us
all out and accept the pricing that does not even make any sense. I know we
cannot make and kind of deal or any kind of standard in this field, that is
illegal. But, how low are we all willing to go? Why do we continue to do
this? I just don't get it.
So, why is it that the insurance companies can do this all the time? What
are they going to do if we all just told them that we refuse to accept the
new low prices? What are their options? Send the patients to a developing
nation where there is cheap labor? Or maybe bring in a bunch of cheap labor
and start making the limbs in some sweat shop here in the US illegally.
Maybe there are already companies in this field that are already doing this
and that is how they can afford to make the limbs at the dirt cheap prices
that they have contracted to. It would not surprise me, and ABC will surely
make sure that these people have some good credentials behind their names to
boot.
An interesting thing has happened here in my state as well. In
Indianapolis, there is a large medical group, basically any doctor that is
in a certain specialty belongs to this group. Any patient that needs this
kind of medical care basically has one choice, which is this huge group
(about 95 doctors and their own hospital even). When Anthem cut the prices
last year, this group told them to forget it. Also, Anthem had made the
decision at the same time that there are no longer any out of network
benefits (I know, because I have Anthem personally, that is the only option
I have here in this area for a small business). So, when this entire group
pulled out, it left a couple million people without any access to this
specialty. That is a big problem, and Anthem knew that. So after a few
months of fighting, negotiating, and a potential lawsuit looming over them
for not providing qualified care to the insured, Anthem had to finally come
to the terms of the doctors and they got what they wanted. Anthem had no
choice. They also did this with this other insurance company that I was
just talking about.
Here locally, the same thing happened with another group (anesthesiology)
that is one big group that includes all the anesthesiologists here in the
city. Anthem did it to them, cut the prices down by 30% or something, and
they said no way. And for about 3 months I had no access to any
anesthesiology, and thank goodness I did not have any surgery planned or was
not in any accident. I would have either had to go through the procedure
without anesthesia or pay lots of money for it, when I was also paying for
my insurance that has a contract with me to provide the service. I did
contact a big law firm and they were actively working on a law suit against
Anthem.
I have seen how this all works and what it takes to get the attention of the
insurance companies. Only the large medical groups can have the leverage to
make a stand against them. We can talk about laws and parity issues to try
to help the situation. But, will these really work? I don't know.
As long as we have some of our so called allies working in our leadership
organizations that are supposedly fighting for us, and they have their own
vested interests working in insurance companies, whether it is a network, or
3rd party payors, or whatever, do you think that anything good will happen
for us? When I see some of the names that are on the board of directors
for AOPA or the leaders of other organizations, and then I see what they are
involved in with insurance issues, or protecting a large O&P company, or
manufacturer, it really makes me wonder. Who are these people more loyal
to? What is in it for them personally?
This new group that was just set up to represent the various organizations,
and they say they are going to pull together to be unified, who are these
people? Why don't we know the names? Are they the same people that were
there in the last battle that failed so miserably? Why don't we hear more
about that? Are they really going to act differently than last time? Or is
it just the same people, same manners, same colors, just a different name?
Just because you slap a Mercedes emblem on the hood of a Yugo, does it
instantly make the car a luxury car? Will the car actually run and be
reliable?
All we do is sit and worry that the PTs are going to steal our business
away. Well, we might not have to worry about it for very long, because we
will destroy this field and nobody will want to do it. We won't be able to
find anyone that will want to do this work, especially if we keep on
discounting our work and end up not being able to make any money to live on.
Nobody in their right mind would want to do it at that point. So, maybe
that will keep the PTs out. Is that the plan that we are using, and I just
haven't heard about it?
I am sure I have hit a lot of nerves with this post, so please be gentle
with me. I have been reading all the posts for the past few months,
thinking about what to say. This finally just got to me where I felt like I
should say something, maybe I should have kept my mouth shut, hands tied, or
whatever and not said anything.
We need to think about all the contracts we have, make a decision as to what
the long term effects are for doing the discounted services. It is
absolutely wrong that an insurance salesman can lie to me and tell me that I
am the only one getting paid at one level, but it is illegal for me to call
another practitioner and ask him/her what they are getting paid. That is
why I have certain patients that can call and check on this for me. Where
is the ACA on this? Why don't they produce some Consumers' Guide to
insurance companies, and let the amputees and the world know who are the
good companies that we should support and work with, and who the bad ones
are?
There are many things that we can do to change this, and we all need to be
vigilant in what we do and protect this field.
Jim DeWees, CP
I have been thinking about what to post or how to respond to this issue. I
have had very similar issues here in the midwest, the worst one was about 6
months ago. A large insurance company no longer does its own contracting,
and has another company that does all the ancillary management for them.
So, all of the sudden my contract with the insurance company was no longer
any good, and I had to redo the contract now through the other company. I
was told that the pricing would not change, it was just the process that was
changing. I asked them for a list of codes with dollar amounts on it, and
they provided it to me. It was HORRIBLE. The pricing was incredibly
different. The L-5981 (Flex Foot of equal) was only paying $1350, which
does not even come close to covering the cost of a Modular III foot. The
silicone liners were only being paid at $165, which is well below the cost
of most liners. All the codes were about the same as these, very much below
medicare and medicaid. I had to decline on the contract, telling them that
I would loose money on every single prosthesis that I would make for them.
It was not a matter of not making enough money to make it worth my time, but
it was just that the cost of the components and materials cost more than
what they were paying me.
So after a few very bad conversations with them, and also having a very
vocal patient that works for a large school system that uses this insurance
get involved, things started to change. First off, I had the patient go to
the school board, explain that because of the very poor pricing of this
certain insurance company, he was requesting the school system look for a
different insurance company that would actually let the employees have
access to better doctors and health care providers. He showed the board a
few examples of what medicaid pays to providers, and what this insurance
company was paying for the same procedure codes. His final statement was
that it is a sad day when a person that has no job, no money, no insurance
(except for medicaid which is for the poor or disabled) has better coverage
than what a school teacher, or anyone else that might have this insurance.
So, the school board chose to change to a different insurance company.
This got the attention of the insurance company, they don't like it when
they lose the contracts of their paying customers.
Also, at this time we had a meeting in the area where many of the
practitioners were attending, and I talked with them casually about this
issue, knowing very well that we cannot discuss too much about anything like
this, but we can talk. We were all in the same boat. But, there was one
that sold us all out.
When I talked with another person at this insurance company, I told them I
was also an amputee, a member of the ACA, and that I could do my best to
influence all other practitioners and facilities to not sign on with them,
and if they have no providers in this area, then they are open to a class
action law suit from the insured because there are no providers. They are
required to have providers for the insured, and they know that. In fact,
many of us in this area did not sign on, and I think they must have started
to worry a little. Shortly after all this, I got an email with a NEW price
sheet attached. They prices went up a little bit, but still not even close
to the old figures before the change took place. I still told them no.
Then the next day I got another email, with different prices, but still
insulting. I said no to that one also. Finally, I got an email that
afternoon, which the pricing the same as the old numbers, (which is better
than Anthem, but that is not saying much).
In the email, the slimy salesman used the tactic that he was able to get MY
prices back to the same as what they used to be, which is a lot higher than
any other provider in this region. In fact, I was the ONLY person that he
was able to make this deal for. And, I had until that afternoon to either
take it or leave it. I told him that was a very insulting way to do
business, it was worse than going and buying a used car...Have I got a deal
for you, if you buy it now...
The other thing that was discussed, when I told him that as a member of the
ACA I would do everything to influence the prosthetists here to not sign
with them, he told me that did not matter to him. They are always protected
from that. They have a nationwide contract with a major company (I think we
all know who that would be), so they do have a provider in this area, and
they are contracted at the lower prices, that is what they signed on right
at the very beginning.
Again, how many times have we seen our very own people in this field sell us
all out and accept the pricing that does not even make any sense. I know we
cannot make and kind of deal or any kind of standard in this field, that is
illegal. But, how low are we all willing to go? Why do we continue to do
this? I just don't get it.
So, why is it that the insurance companies can do this all the time? What
are they going to do if we all just told them that we refuse to accept the
new low prices? What are their options? Send the patients to a developing
nation where there is cheap labor? Or maybe bring in a bunch of cheap labor
and start making the limbs in some sweat shop here in the US illegally.
Maybe there are already companies in this field that are already doing this
and that is how they can afford to make the limbs at the dirt cheap prices
that they have contracted to. It would not surprise me, and ABC will surely
make sure that these people have some good credentials behind their names to
boot.
An interesting thing has happened here in my state as well. In
Indianapolis, there is a large medical group, basically any doctor that is
in a certain specialty belongs to this group. Any patient that needs this
kind of medical care basically has one choice, which is this huge group
(about 95 doctors and their own hospital even). When Anthem cut the prices
last year, this group told them to forget it. Also, Anthem had made the
decision at the same time that there are no longer any out of network
benefits (I know, because I have Anthem personally, that is the only option
I have here in this area for a small business). So, when this entire group
pulled out, it left a couple million people without any access to this
specialty. That is a big problem, and Anthem knew that. So after a few
months of fighting, negotiating, and a potential lawsuit looming over them
for not providing qualified care to the insured, Anthem had to finally come
to the terms of the doctors and they got what they wanted. Anthem had no
choice. They also did this with this other insurance company that I was
just talking about.
Here locally, the same thing happened with another group (anesthesiology)
that is one big group that includes all the anesthesiologists here in the
city. Anthem did it to them, cut the prices down by 30% or something, and
they said no way. And for about 3 months I had no access to any
anesthesiology, and thank goodness I did not have any surgery planned or was
not in any accident. I would have either had to go through the procedure
without anesthesia or pay lots of money for it, when I was also paying for
my insurance that has a contract with me to provide the service. I did
contact a big law firm and they were actively working on a law suit against
Anthem.
I have seen how this all works and what it takes to get the attention of the
insurance companies. Only the large medical groups can have the leverage to
make a stand against them. We can talk about laws and parity issues to try
to help the situation. But, will these really work? I don't know.
As long as we have some of our so called allies working in our leadership
organizations that are supposedly fighting for us, and they have their own
vested interests working in insurance companies, whether it is a network, or
3rd party payors, or whatever, do you think that anything good will happen
for us? When I see some of the names that are on the board of directors
for AOPA or the leaders of other organizations, and then I see what they are
involved in with insurance issues, or protecting a large O&P company, or
manufacturer, it really makes me wonder. Who are these people more loyal
to? What is in it for them personally?
This new group that was just set up to represent the various organizations,
and they say they are going to pull together to be unified, who are these
people? Why don't we know the names? Are they the same people that were
there in the last battle that failed so miserably? Why don't we hear more
about that? Are they really going to act differently than last time? Or is
it just the same people, same manners, same colors, just a different name?
Just because you slap a Mercedes emblem on the hood of a Yugo, does it
instantly make the car a luxury car? Will the car actually run and be
reliable?
All we do is sit and worry that the PTs are going to steal our business
away. Well, we might not have to worry about it for very long, because we
will destroy this field and nobody will want to do it. We won't be able to
find anyone that will want to do this work, especially if we keep on
discounting our work and end up not being able to make any money to live on.
Nobody in their right mind would want to do it at that point. So, maybe
that will keep the PTs out. Is that the plan that we are using, and I just
haven't heard about it?
I am sure I have hit a lot of nerves with this post, so please be gentle
with me. I have been reading all the posts for the past few months,
thinking about what to say. This finally just got to me where I felt like I
should say something, maybe I should have kept my mouth shut, hands tied, or
whatever and not said anything.
We need to think about all the contracts we have, make a decision as to what
the long term effects are for doing the discounted services. It is
absolutely wrong that an insurance salesman can lie to me and tell me that I
am the only one getting paid at one level, but it is illegal for me to call
another practitioner and ask him/her what they are getting paid. That is
why I have certain patients that can call and check on this for me. Where
is the ACA on this? Why don't they produce some Consumers' Guide to
insurance companies, and let the amputees and the world know who are the
good companies that we should support and work with, and who the bad ones
are?
There are many things that we can do to change this, and we all need to be
vigilant in what we do and protect this field.
Jim DeWees, CP
Citation
Jim DeWees, “Re: FW: Unethical tactics by MCOs- RESPONSES,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 4, 2024, https://library.drfop.org/items/show/226619.
