DPA Report

803
Spring 2016: Volume 72, Number 1
 by Lucy Homans, Ed.D.

Writing this first WP column for the first time in many months, I feel a bit like the old advertisement for American Express cards: “Do you know me?” In my case, it would be: “Do you remember me?” Either way, I am delighted that the WP is back!

No doubt, the issue most on members’ minds right now is the Regence BlueShield reimbursement rate reduction for the CPT code 90837 – and the static rate for 90834. I am sure you all remember that a year ago Regence first reduced the 90837 code reimbursement to the same rate as 90834. At that time WSPA filed a complaint with the Office of the Insurance Commissioner (OIC), after which Regence backed off that effort, but decided ultimately to leave the 90834 rate where it was and just reduce the 90837 rate to slightly above 90834. This was all done expressly by Regence to punish providers for “incorrectly” using 90837 as the equivalent code to the old 90806 code. To date, Regence has not budged from this position.

WSPA in response has contacted a health law expert to analyze all the materials, including a public records request for all relevant documents at the OIC, copies of the Regence provider contract and supporting fee related documents.  In addition, psychologists in Utah where Regence is also a major insurer have filed a lengthy complaint with the Utah Insurance Commissioner. We are awaiting both responses.

We are concerned that since Regence backed off completely collapsing the 90837 code rate to the 90834 level it may be difficult to make the argument that what Regence is now doing is some sort of camouflaged treatment limit (which would be a violation of our state mental health parity mandate). Not impossible, but more difficult. We are still working on the answer to this question with our attorney so I beg your patience a little bit longer. Several loyal WSPA members have provided me (since I am no longer in clinical practice) with a current Regence contract and supporting material for our attorney to enjoy, and I thank you very much! You know who you are!

Just barely second to Regence in emails to me this year are complaints about Optum/United Healthcare. It’s not just that they have attached the equivalence of a stranglehold on use of the 90837 CPT code. In fact the problems are less clinical and more incredibly frustrating administrative mistakes.

These errors, oversights and other goofs drove me finally to send an email to our colleague, Dr. Bruce Bobbitt, CEO of Optum outlining at length the litany of customer service and provider relations bungles occurring here by his company’s employees. I never heard back from him, and unlike my Evil Twin Skippy, I was quite polite.

However, once again loyal WSPA members have come to the rescue! Several of you have spent hours getting problems like the following fixed: neglect to post a change of provider address correctly so that re-credentialing materials for a colleague were lost resulting in denied reimbursements; incorrect information given to patients; significant claims processing errors; referrals by Customer Service to Provider Relations, who refer back to Customer Relations because each is unclear as to what the job responsibilities are of the other; and finally an unconscionable neglect to notify enrollees of a major hospital system, with insurance through one company and behavioral health services managed by Optum, that for care to be reimbursed providers must be in-network with both companies. Neither Skippy nor I have adequate words for such an oversight.

The good news is that our colleagues who have managed to successfully correct some of these problems have shared with me the names of staff in both Customer Service and Provider Relations who have helped them. So, if you are struggling with an Optum/UHC mess, send me an email and I will give you some contact information. And, THANK YOU LOYAL WSPA MEMBERS!

Just, FYI, the above-mentioned plan offered by the hospital system is a union negotiated plan. All union plans are by definition self insured or ERISA based plans that are not subject to state regulation. In addition, state Attorney General consumer protection offices may not regulate union negotiated plans either.

Elsewhere in this edition of the WP, you will find two more articles that I have submitted, one about risk adjustment audits, and another about HIPAA security requirements. Please read them. As always, I can’t help you if you don’t contact me and the easiest way to do that is via email at lucy.homans@gmail.com

      Thank you,
      Lucy Homans