Indiana Parity finally in place

Indiana Parity finally in place

Jim DeWees

7/16/2008

I just wanted to share a little on the Indiana Parity bill that was signed this year and went into effect on July 1, 2008. Last month in one of the O&P magazines, there was a full page dedicated to Rep. Murphy that was the author of this bill, and it sure sounded like he was a friend to the amputee group and that he really did a lot of help here. Also, the ACA has called this one of the most comprehensive bills that has been passed. There were a lot of people in Indiana that spent a lot of time and energy (not to mention money) to get this passed, and I appreciate most of their efforts here. I don't want to offend anyone for their hard work, especially those that had the same ideals and values that I had for this bill. I know that there are some that are not happy with how this ended up, and don't call it a total victory, and they are not happy about that, but claim it is a good place to keep on moving ahead with a better one. But, having this bill called the 'most comprehensive bill' out there is really stretching it. Here is the link to the bill for you to read it: <URL Redacted> At the first glance, it sure sounds good: Medicare pricing at a minimum, and providing the same benefits as the Medicare policy, a lifetime cap that is equal to the insurance policy cap for all medical coverage, etc. But, let's take these one at a time. First off, it mandates that the insurance has to pay at least Medicare rates for the same repair, device, service, etc, but then goes on to state 'Unless there is a contractual negotiated rate' with the provider. In Indiana, and I assume for many states, most (if not all) insurance companies require the providers to be in-network to do any work, or the insurance company has extremely high deductibles and copay amounts, along with a 50% coverage, that make it virtually impossible to do out-of-network services. So, basically this medicare pricing statement is totally worthless in this case. There is no 'negotiations' that ever take place with any insurance contract. It is always 'here's our rates...take it or leave it'. This not only allows the insurance companies to pay whatever they want to pay, but also gives them the power to make these contracts that are not good for the patients. There are already a few contracts out there that pay well below the cost of the components, and I am not in those networks. But, this bill is not about me and my business, this bill is supposed to be about the amputee, and why he/she can't find a facility that is convenient or with high standards or quality, but is forced to travel to some facility that has found a way to stay in business by using something that costs less than what the insurance is paying. I had a solution to this issue, which the ACA wasn't interested in at all (caused a huge problem to be more precise), and therefore the group here in Indiana wasn't interested in either. My solution was to add a clause in there that states that any amputee has the right to choose any prosthetist/facility that has a valid Medicare provider ID number, regarldess of their network. The bill uses medicare pricing, and guidelines, and so why not also include the medicare validation of credentials as well. This way, it would make these networks totally worthless, and the providers could all drop their contracts with these companies, and there would be no 'negotiated rates' to worry about. This would allow all amputees (with the health insurance that falls under this law) to get the appropriate care and the best quality devices possible and necessary for them. But, nobody here wanted to fight for the 'freedom to choose' or the 'right to choose' their providers. The amputee's care is still being managed by the corporations now, and it is all about the contracts and the money. Is it any wonder that Rep. Murphy, the author of this bill, used to work for Anthem/Wellpoint, and how this bill still favors the insurance business and not the amputees? I don't know him personally, but this bill does nothing to help the amputees in my view. Being an amputee and having a son that is also missing a limb (adopted from China) gives me a lot of reason to be concerned about this bill, and also being a prosthetist and owner of a facility adds to that interest and concern. He obviously still has good connections with his former employer, or something. Next, it states in the bill that the insurance has to pay for devices that the patient's physician prescribes, and attaches that to being under the medicare guidelines as well (which was pretty much intended for the microprocessor devices like knees, hands, etc.), and that sounds good. But, then it states later that these services are able to be reviewed by the utilization or periodic reviews by the insurance companies to determine if these are necessary services/devices. This is one of the biggest battles that we face here with the BIG insurance company here in the area, their 'Utilization Management Dept.' They can deny claims or pre-certification requests for any reason, or just state that they need more information to make a decision. They give 10 days to submit the additional information, or then it has to go through the appeals process. But, the envelope has postmarks on them that are anywhere from 6-10 days after the letter is generated, which is during the time that the clock it ticking. The letters about these decisions are not ever received in time to submit the information. They can decide that a new prosthetic leg is not medically necessary for any reason, and that is all it takes. The only way to fight that is by an appeals process that can take weeks and weeks to get approved. And, as far as microprocessors...there is another clause in the bill stating that these devices are not intended for convenience of comfort. So, what is the line where that distinction is made....a peg leg is functional, and a prosthetic foot is just for convenience now. Or, a Flex Foot....who needs that, a peg leg works just fine. Not to mention anything about microprocessors. These 2 clauses or exceptions here totally negate anything about the odering physician being able to prescribe any device, again favoring the insurance companies in a major way. The part about the lifetime or annual limits. This is one victory for this bill, but it may not ever really matter now. If there is still a way for the Utilization management team to make random decisions about a new prosthetic leg being needed or not (which is generally NOT), then these caps don't really matter. And, then who is going to enforce these rules anyway? What is the penalty for an insurance company not complying with this ruling? Just to share with everyone what I learned after meeting with the State Dept of Insurance a few months ago, I filed a complaint against a Third Party Administration network about not being allowed to be in their network. During the state House hearings, I had to sit through the dialysis hearing, and one provider was explaining about not being allowed into a network. He was really chastised for not filing a complaint with the dept or insurance, because 'there are laws that prohibit this kind of issue'. The one member of the board that did this and got onto the provider about this was Rep. Murphy. He was actually the only one on the board/panel that came to Anthem's defense in front of these dialysis patients, which really struck me at that time. Anyway, I decided to file a complaint against a big network in this field. It was determined by the State Dept of Insurance that this is not legal for them to not allow anyone into their network as long as the facility meets the requirements, BUT, there is nobody that can do anything to a Third Party Administrator, or a Network administration group. These entities are NOT insurance companies and do not have to be licensed or registered in this state to do their work. There is no government agency that has jurisdiction over a TPA. Many of our problems that are going to come up with this new law will be with TPA entities that administer the benefits and make the decisions and process the claims. If they are not following the new laws, we can file a complaint with the Dept of Insurance, but there is nothing they can do about it to make a TPA pay the claims or abide by the law. I encourage every state that is working on Parity to check with you Dept of Insurance and see if you can get a straight answer from someone there about TPA's being under their jurisdiction. From what I have been able to find out is that most states do not have power over any TPA. I just wanted to share this and hope to help others working on these bills spend their time to make effective rulings and policies that will help the amputees and others that need our services. Again, I do want to thank everyone in Indiana for their hard work, and all the frustrations and everything they went through. But, I am still working behind the scenes on this bill, meeting with people about this bill and working on some ammendments that should come up here sometime. I did nothing, and am doing nothing, that would derail this bill. But I decided if the ACA and the Indiana coalition isn't going to work for amputees to have the freedom to choose their providers, then I am going to work on it myself, and educate the lawmakers what this network stuff is all about, and how it affects people's lives and can interfere with them getting the appropriate care. Another issue that I heard was kind of a big red-flag was on the issue of having the Orthotics portion added on to this bill. And, for the record, since I am in this field working, I am in favor of having Orthotics on this bill. But, this bill was being fought for by the amputees, supposedly. There were amputees at the hearings sharing their stories and everything, making it look like it was for the amputees and to help the amputees. But, many people that had to vote on this bill realized that when the Orthotics got thrown on to the bill, it appeared that it was being really backed by the industry and the field, more than by the amputees. There are not many amputees that really care about orthotics or have anything to do with orthotics. I do feel like this needs to be on the bill as well, but there has to be a better way to present that and add it. There were a few people that noticed that and commented on that to me during some of my discussions. Again, I am just posting this for others that are in the process of working on Parity in their states, or considering this fight. Hopefully you will consider all the issues and how it all makes an impact on the amputees and the field. Thanks, Jim DeWees, CP
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