DAVID ROSENFELD

The Florida Medical Association came away with a win this legislative session heralded as one of the most significant managed care reform laws in more than a decade.

The law, known as the Managed Care Bill (SB 1012), most notably prevents insurers from reversing payments up to 30 months after dolling them out. Instead, insurers will have just 12 months to re-open claims for possible reversal in addition to a six-month review period already in existence. Insurers use this so-called “look-back period” to take a closer look at medical necessity.

“We had received complaints from almost all over the state,” said Michael Wasylik, MD, past president of the Hillsborough County Medical Society and current chair of the Florida Medical Association’s managed care committee. “I think almost every doctor has seen this happen.”

Doctors complain that insurer requests for medical records are burdensome and proving the need for a particular service more than two years later is unreasonable. An orthopedic clinic in Orlando recently lost $50,000 to a large-scale claims review.

“A doctor has no recollection of the claim two-and-a-half years later,” said Jeff Scott, director of legal and government affairs.

Lobbyists for insurance companies mounted heavy opposition to the bill during the session. They had plenty of opportunity, too, as the bill wound its way through a legislative gauntlet of eight separate committees. In arguing against the bill, insurers said it would cost them millions. Lobbyists for Blue Cross and Blue Shield of Florida said shortening the look-back period would cost the state employee health plan $70 million. But supporters of the bill, led by Sen. Don Gaetz (R-Niceville), pointed to other states where similar legislation was passed, which did not support opponents’ assertions.

“Insurers will just review their bills faster,” said Scott.

Health insurers had originally opposed the bill, but were satisfied enough with the compromise to support it in the end, said Jim Bracher, executive vice president for the Florida Association of Health Plans. The point of allowing insurers to look back at their claims over a lengthy period, said Bracher, is for insurers to notice trends that should trigger further review.

“The issue is having a sufficient period of time,” Bracher said. “Plans were concerned that 12 months wouldn’t be sufficient time to do a good analysis of claims. This concern was a particular one related to physicians as opposed to hospitals. Many physicians who you might have in your network don’t see patients every day. A key part of an audit is to have sufficient volume of claims so you can determine trends and that sort of thing.”

The second aspect of the bill brings transparency to shared contracts under PPOs. Known as a silent PPO, doctors may sign a contract with one PPO network only to have that network sold to another insurer and likewise be contracted multiple times without their knowledge. The Tampa Eye Clinic testified to a case where they accepted a reduced rate for the sole reason of treating a specific patient. That contract was then carried over to the majority of their business, putting them in a financial hardship. The FMA argued that this practice is a substantial violation of trust.

“We were supportive of the idea that providers needed to have a way to be aware of who they were contracting with,” Bracher said. “That was an issue where there was agreement on both sides.”

Network contracts are a crucial aspect for managed care plans which promise providers prompt payment and an influx of patients while at the same time promising patients a cadre of quality, affordable providers. The new law will require that doctors are notified when their contracts are shared.

“The law takes silence out of the silent PPO and provides transparency,” said Scott of the FMA. “The doctor has to be told out front that information can be sold or leased and given an opportunity to find out who it’s being sold to. The law also requires that the original contract terms follow the leased information. Other insurers who try and rent a network will often try and get a discount that’s even steeper than the doctor had agreed to.”

The last thing the bill accomplished related to payments from insurers that are sent to patients rather than their doctor. But too often, patients keep the money instead of passing on the check. Addiction doctors testified to the legislature that insurers were actually sending checks to patients who used the money to buy drugs, completely undermining their treatment plans. This situation occurs more often with relation to out-of-network or non-participating providers, but the bill only applies to in-network doctors.

“We may go after that next,” said Scott of the FMA.

“Insurers basically do that because they want to discourage patients from going to non-participating providers,” Wasylik said. “They figure if non-pars don’t get paid, they won’t see them.”



August 2008