• Area Health Plans & Contact Information
• Rental/Silent PPOs
• Store-Based Retail Clinics
• Contract Terminology
• Budget Neutrality Adjuster
• Health Plan News
• Multi-District Litigation Settlements
• Physician Payment
Indemnity and PPO-based benefit plans: 1 (800) MD-AETNA (632-3862)
HMO benefits plans: 1 (800) 624-0756
Provider Relations: 1 (800) 882-4462
Health Net Health Plan of Oregon
Provider Contact Center: 1 (888) 802-7001
Kaiser Permanente Northwest
Claims Administration & Billing: 1 (800) 813-2000
Lifewise Health Plan of Oregon
Provider Relations: 1 (800) 596-3382, option 4
ODS Health Plan
Professional Services Line: (503) 243-3968; Toll Free: 1 (877) 337-0650
PacificSource Health Plans
Provider Network: (541) 684-5580; Toll Free: 1 (800) 624-6052
Providence Health Plans
Customer Service: (503) 574-7500; Toll Free: 1 (800) 878-4445
Regence BlueCross BlueShield of Oregon
Provider Customer Service Portland: (503) 225-6619; Toll Free: 1 (800) 722-5086
Provider Customer Service Salem: (503) 371-3249; Toll Free: 1 (800) 228-0978
Health Care Professionals Line: 1 (877) 842-3210
The Rental PPO Issue
Rental PPOs, also known derogatorily as Silent PPOs, are entities whose key function is to market and broker physicians’ contractually discounted rates. Rental PPOs establish a network panel of health care providers and then lease provider discounts associated with the network to various payers. These could include insurance brokers, local and regional PPOs, third-party administrators or self-insured employers. Due to lack of regulations in the PPO industry, more and more companies are profiting from the creation and rental of PPO networks. While physicians contract with these entities to lease their discount rates in certain circumstances, discounts are frequently extended to a broader range of entities without notice or physician approval. These entities often exist and operate in secret, and discounts are given without many physicians’ or patients’ knowledge.
When access to contractual network discounts is inappropriately given to third party entities, physicians are reimbursed at lower levels than they should be. This becomes a particular problem when rental network PPOs or those renting the network proceed to lease the network to non-payers, such as “network brokers” or “repricers.” In these cases, various payers use these entities to access the lowest possible discounts and “reprice” their claims. Often these discounts were never agreed upon contractually and have not been earned, as the PPO may have played no role in promoting a particular physician’s practice.
This secondary market has been around for years, but it continues to grow more prevalent. Hundreds of such entities operate in the United States with little or no regulatory oversight. The American Medical Association (AMA) advocates regulation of the PPO market in order to stop unauthorized discounting and is working with a national coalition of health insurers to draft legislation that fits the needs of both physicians and insurers. Bills regulating the rental network secondary market were passed in Connecticut, Florida, Indiana and Ohio during the 2008 legislative session, and California and Texas are taking steps to regulate these markets as well. A subcommittee of the OMA’s Health Care Finance Committee is looking into possible legislation in Oregon.
According to a 2007 Internal Medicine World Report article:
“The number of retail clinics has grown over the past 2 years, and a recent survey suggests that about 5% of US adults have visited these types of clinics. At a time when many patients are concerned about the costs and quality of healthcare, the majority of those who have used in-store clinics say that they are satisfied with the quality of care, cost, and convenience of these clinics. ”
“Mary Kate Scott, author of "Health Care in the Express Lane: The Emergence of Retail Clinics," commissioned by the California HealthCare Foundation, says the number of such clinics is projected to grow from 330 today (May 2007) to 1500 by the end of 2008.”
“Based on the expansion plans of major operators in the field, some experts estimate there will be 2,000 clinics in 2009…”
Retail Clinics in Oregon
- Take Care Health Systems (operated out of Rite-Aid) exited the Oregon Market in 2006 due to lack of patient demand.
- There is one Minute Clinic in Oregon (Portland West Hills - inside QFC).
OMA Policies Regarding Store-Based Clinics
OMA adopted the AMA’s policy regarding store-based clinics at the A-07 HOD meeting as recommended by this committee.
1. Have a well-defined and limited scope of clinical services, consistent with state practice laws.
2. Use standardized medical protocols derived from evidence-based practice guidelines.
3. Establish arrangements by which their healthcare practitioners have direct access to and super-vision by those with medical degrees (MD and DO).
4. Establish protocols for ensuring continuity of care with practicing physicians in the local community.
5. Establish a referral system with physician practices or other facilities for appropriate treatment.
6. Inform patients of the qualifications of the healthcare practitioners who are providing care, and the types of illnesses they can diagnose and treat.
7. Establish appropriate sanitation and hygienic guidelines.
8. Use electronic health records as a means of communicating patient information and facilitating continuity of care.
9. Encourage patients to have a primary care physician to ensure continuity of care.
Because there are currently a small number of store-based clinics in Oregon, the committee decided to limit the monitoring of this issue at this time.
1 McCallister, R. (2007) In-Store Clinics: Threat or Help to Primary Care? May 2007 Issue of Internal Medicine World Report. Retrieved from we on April 2, 2008. www.imwr.com/issues/articles/2007-05_03.asp.
2 Chin, T. (2006) In-Store Clinic Operator Pulls Out of Oregon Market. AMA News. 23 Oct. 2006. Retrieved from web April 2, 2008. www.ama-assn.org/amednews/2006/10/23/bisc1023.htm.
OMA’s Contracting Workshop Series
In the past few years, insurance companies have discontinued offering commercial "risk" contracts to physicians. To abide by Federal and State legal guidelines, physicians must now independently and individually assess and negotiate commercial contracts directly with insurers. To have a greater impact on the contracting process, physicians must be equipped with the tools necessary to deal directly with the insurance companies. The OMA offers a two-part educational workshop designed to help physicians and office managers obtain more favorable contracts and assure that companies are adhering to the payment terms and conditions of those contracts. For more information, visit www.theoma.org/workshops.
As reported at the A-07 House of Delegates, following are the issues reported by OMA members:
- Timely credentialing is an issue, reportedly taking longer than 60 days for some health plans.
- Physicians may be credentialed at many locations (hospitals, Medicaid, Medicare, Licensing, and all other health plans). There is no one location for information.
- Physicians whose practices relocate, merge or otherwise change status are subjected to the credentialing process as though they were new to practice.
- Health plans cite NCQA and other accreditation requirements for policies they put into place.
- It is sometimes unclear how the physician should bill for services provided before he/she is credentialed. Some health plans allow this and offer different mechanisms to assure payment; others do not allow physicians to bill for services provided forcing the practice to cover these costs. With the sunset of SB 1182, there is no longer a state regulation in place stating allowing for payment while a physician is going through the credentialing process.
- Credentialing issues such as coverage for physicians with no hospital privileges or requirements that are not consistent with the standard of care in a community have also been reported.
Numerous questions regarding both hospital and health plan credentialing were asked in the Membership Survey conducted early in 2008. Results will be available later this spring. The data will provide a baseline for credentialing concerns in Oregon including: data on refusal of credentialing by health plans, reason for denial of credentialing, refusal or denial of privileges, reasons for refusal or denial or privileges, data on revocation of privileges, and reasons for the revocation.
The PEER program was developed by the OMA 15 years ago. Its development was in response to the need for a way to assist physicians whose medical practices had been questioned and who were faced with possible limitation of practice, privileges or access of patients. The PEER program, through its medical director, Roy Skoglund, M.D., evaluates the concerns or perceived problems in their practice with the goal of defining and correcting the problems identified.
Several physicians going through the PEER process have had some credentialing issues with health plans. The committee is examining whether or not it is valid for third party payers to drop individual physicians from provider panels because of an action by the Oregon Medical Board and whether or not it is valid to drop individuals whether the board action is disciplinary or not disciplinary. The committee will provide information on PEER to the health plan credentialing managers to educate them on this program.
Beware the Budget Neutrality Adjuster in Some Contracts
(from STAT, April 10, 2008 – Volume XXXVIII, NO. 4)
Some contracts offered locally use the Budget Neutrality Work Adjuster (BNWA) as part of their reimbursement rate for commercial plans. Use of the BNWA, the work component of the RVU, ultimately decreases the total RVU and therefore decreases total reimbursement. Members should note that differences will occur between specialties and that even if health plans offer an increase in the conversion factor for the upcoming year, if the plan uses the BNWA, it could still result in a reimbursement decrease.
To calculate 2008 Medicare reimbursement rates, Medicare applies the BNWA factor of 0.8806 to the work Relative Value Units (RVUs). The Omnibus Budget Reconciliation Act of 1989 requires that increases or decreases in RVUs for a year may not cause the amount of expenditures to differ by more than $20 million from what the expenditures would have been in the absence of these changes. To limit growth in Medicare expenditures, the Centers for Medicare and Medicaid Services (CMS) has applied various adjustments to the Medicare Physician Payment Schedule, usually to the conversion factor. Recognizing that budget neutrality is mandated legislatively for monetary reasons, the OMA, AMA and others favor budget neutrality adjustments be made to the conversion factor, rather than the BNWA.