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It has been about three weeks since I contacted the top five managed care organizations for a customer of ours. The purpose of my initial call was to obtain their current agreement and fee schedule for their top five payers. I started as if I had no experience or contacts in the field to see how long it would take to obtain the proper information. Here is the update by managed care plan:

1. Aetna: The Physician Network Account Manager on 12/2/10 stated that I would receive the information via e-mail within 3 business days. I called at the end of the third business day to check on the status. She did not call me back until I called again and sent and an e-mail to her as a follow-up (10 business days after our original call). After some further back and forth via e-mail (few hours), I was able to obtain a copy of the agreement as well as fee schedule.
2. IBC: Independent Blue Cross (IBC) – the office had to request the information, sign a document, follow-up with the representative. IBC provided the agreement and fee schedule by 12/17/10.
3. Highmark: The most disappointing of the five carriers. After a few phone calls and e-mails the network representative provided a general mailbox (estprovcred@highmark.com) for contract and fee schedule requests. She stated would only take 1-2 business days. I followed up after 10 business days and still have no response or information. The Network Representative is out of the office from 12/23/10 until 1/3/11 due to the holidays. I left a message and will need to follow-up again in a few weeks.
4. Cigna: The representatives (888-992-4462) stated there is no provider representative and could only provide a fax for this information. Cigna would not expect a Pediatric Office to not provide the name of their doctors or not to provide the location of their doctors when they need help, why do they avoid their providers when requesting simple information related to contracting? The woman on the phone stated that we need to send an urgent fax (866-463-6175) and that there might be a provider representative that would call us back. We sent the fax, as instructed, 10 business days ago, no one called as of yet. Today, at the main number, they instructed me to send another fax to the same number.
5. United Healthcare: The Network Manager (obtained proper information by calling 877-842-3210) was good at providing the fee schedule and initial follow-up. He was available we I called or followed-up within a few days. There were a few additional codes missing from the fee schedule for which I requested the information and he was able to obtain after a telephone call.

The commitment to follow-up on contractual items is very inconsistent with the Health Plans (even if the representative states they will follow-up). Due to this, the burden of follow-up is on the provider’s office or the company that works for the provider’s office.

The HITECH Act has an Electronic Health Record (EHR) incentive program paid via either Medicare or Medicaid. Since Pediatricians do not have Medicare Patients, their opportunity to participate is via the EHR incentive program provided by the Medicaid program. The Medicaid program starts as early as 2011 and eligible providers in a Pediatric Group (MD, DO, NP) can each receive up to $63,750 over a six year period. Unlike Medicare, eligible professionals have until 2016 to implement a certified E.H.R. system and still qualify for the maximum incentive. The HITECH act has recommendations to the state of the threshold for this incentive money. A provider must have at least 20% of their total patient volume be via Medicaid/Managed Medicaid/Children Health Insurance Program (CHIP) Patients during a 90-day measurement period. If a provider has 20% Medicaid volume during a 90-day period, they are eligible for up to $42,500 over a six-year period. If a provider has over 30% volume during a 90-day measurement period, they are eligible for up to $63,750 over a six-year period. Note that the “up to” is dependent on maintaining these thresholds each year as well as implementing a certified EHR system to show meaningful use. The table below provides a summary by year.

Medicaid Eligible Professional (20% – 30% Medicaid/Managed Medicaid/CHIP vol.)

Medicaid, different than Medicare, is administered by the state. The state Medicaid programs are required to verify the eligibility of the provider as well as disperse the payments. Per the CMS.gov website: “The Medicaid EHR Incentive Program is voluntarily offered by individual states and territories and may begin as early as 2011, depending on the state.”

The question and answer section on the CMS website related to the Medicaid EHR program I found to be a useful resource (22 pages). One of the questions is if the State Medicaid program needs to verify the “installation” or “signed contract” of a certified EHR . The answer on the CMS website concludes that: “Thus, a signed contract indicating that the provider has adopted or upgraded would be sufficient.”

There are details to verify and implement to insure eligibility and then receive disperse these funds. I recommend that each office invest some time learning about the HITECH act. Also, having a knowledgeable EHR vendor and/or consultant should greatly reduce the detail knowledge needed within each office.

http://www.cms.gov/EHRIncentivePrograms/

https://www.cms.gov/apps/media/press/factsheet.asp?Counter=3793&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=6&intPage=&showAll=&pYear=&year=&desc=&cboOrder=date

Most in the medial field know the acronym EHR (Electronic Health Record) and EMR (Electronic Medical Record) but many do not understand the difference between the two. The National Alliance for Health Information Technology defines these two as follows (2008):

Electronic Medical Record: an electronic record of health-related information on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff within one healthcare organization.

Electronic Health Record: an electronic record of health-related information on an individual that conforms to nationally recognized interoperability standards on an individual that can be created, gathered, managed, and consulted by authorized clinicians and staff across more than one healthcare organizations. The United States government via Health and Human Services/Office of the National Coordinator provides incentives via the HITECH Act to move the nation toward adoption of Electronic Health Records. On July 13, 2010, HHS provided a clarification of the benchmarks providers must demonstrate to receive the incentive payments for adopting a “certified EHR”. This document is over 850 pages in length that highlights some of the details of meaningful use. Many thought leaders, providers, and policy makers believe that Moving away from a primary “paper-based” system to an “Electronic Health Record” will improve quality and reduce costs of the health care system. Making the transition requires time, money
and effort.

Technology evolves at a rapid pace. Moore’s law states that processors double in speed about every 18 months. This concept with the computer chip allowed manufacturers to develop personal computers at a low cost. IBM and other large companies focused their sales groups on high profit main frame computers. Businesses learned that they could save money by adopting personal computers. Businesses then Adopted servers with wired connections to personal computers (PC) and installed the software they needed on the server. Businesses that use servers need to pay for the software, the server, and have have IT individuals install firewall protection, conduct back up, maintenance, etc. The high speed Internet now provides a means for businesses, including physician practices to lower their costs and reduce their administrative work via cloud computing (see article related to what is cloud computing?).

Interesting to note the Wall Street Journal article on Monday, July 26, 2010 titled “microsoft, Google Vie to Sell US Cloud Mail”. The author of the article (Amir Efrati) shares two interesting confirmation of using cloud computing for business and government: (1) the General Services Adminstration certified that Google’s cloud-based “e-mail and word-processing service, known as Google Apps, meets security requirements to qualify for use by the agency”. If a large government agency that requires high security of information uses cloud-based solutions, shouldn’t small businesses? And (2) the estimated number of users would be about 15,000 government employees. Note that “the GSA often helps shape how other agencies acquire technology”.

The government understands that cloud-based computing can save money for US taxpayers. The WSJ article states “a report from the Obama administration’s chief information officer says the concept could help trim the federal government’s $76 billion annual budget for computer equipment and software”. The government would pay a set fee per user per year and would only need to maintain an Internet connection.

If the government is moving toward cloud computing with thousands of employees, should any physician practice with less than 100 employees adopt EHR systems based on the practice needing to buy and maintain a server?

A practice should verify their contract terms and fee schedule with the managed care organizations once a year. I was interested to see how long it would take to request this information from the top five payers of one of the practices we managed the billing and collection. Since each company has their own processes and systems, the customer experience varies between the insurance companies. In most cases, it takes time to obtain a representative. Once you are able to make contact with a Customer Service Representative the representative will usually provide you another name and number to call to obtain the information. For this particular practice, my experiences were with Aetna, Highmark, Independence Blue Cross, Cigna and Highmark and are as follows:

1. For Aetna, I called the main number (800)624-0756 and spent 4 minutes moving through the menu options until I requested “Customer Service”. After obtaining a customer service representative, she informed me that I needed to speak with our “Network Account Manager”. She provided me a name and phone number. I called the person. She answered! Unfortunately, she was the person for Hospitals and not physician practices. This representative then informed me that I need to contact the Network Account Manager for Physician Groups in our County. I called the number that she provided and received a message stating that the number has been disconnected. I called the person back whom provided the number (less than 2 minutes) whom did not answer so I left her a message. She called me back and provided me an updated phone number. Fortunately, I was eventually able to speak with the person in our area whom is the Physician Network Account Manager. I stated that we are requesting a current copy of our contract and fee schedule. She stated that the practice does not have a contract but a “Service agreement” for over six years implying that we did not need the information. I needed to state to her that we needed a current copy of the agreement again and she agreed to send the information (stated would take three business days and she would send via e-mail).
2. For Independence Blue Cross (IBC), I called the main number (800-Ask-Blue) and was able to speak with a Customer Service representative whom stated I needed to place this request with the Network Coordinator for PCPs. She provided me her direct phone number for which I left my name, reason for calling, name of the practice, tax id, return phone number and e-mail. I am unsure how long it will take this person to return my call.
3. For Highmark, I called the main phone number (866)975-7290 and was able to speak with a Customer Service Representative very quickly. I informed her of my request and she stated that she needed to fill out a form with the request and would send to the Provider Relations Representative. She was unable to provide me the phone number or other information for this person (was able to provide the first and last name) and stated that the provider relations representative would call me back in 1-2 business days.
4. For Cigna, I called the main number (888)992-4462 and after moving through a few menus obtained an option for “contracting”. The first Customer Service Representative stated that she needed to transfer me to contracting then the second person stated we could obtain the information by sending a fax request to Provider Solutions and Services at (866)463-6175. He stated that I needed to provide the name of the providers, practice name, tax id as well as stating that we need a copy of the contract and fee schedule and the department will follow-up via e-mail (with PDF file) or Fax. After the call I drafted a one page letter as he recommended and sent via fax to the number provided.
5. For United, I called the main number (877)842-3210 at 4:40 pm. When I spoke with a Customer Service Representative, she stated that I needed to call another number and make the request. The number provided [(800)791-2067] is a voice mail box that states to leave the information you request. I left a voice mail providing my name, practice name, the information requested, the practice tax id, my phone number and e-mail. Unsure when or if I will receive a call back as well as the information since there is no person working the line or a name of a person at United to call if there are issues.

This initial process of contacting these five carriers took about an hour. Anticipate that I will need to follow-up with these insurance companies in two days if I do not receive confirmations that they will be sending the information requested.