Fear And Loathing in Columbus, OH (UHC, Humana)

I am in lovely Columbus, OH, about to meet Dr. Lander, Donelle Holle, and some clients for dinner as we prepare for our pediatric coding and practice management event tomorrow morning.  We obviously won’t have the crowds we get in Washington or NYC, but it will be a pretty full room still!  If you are one of the blog readers, say hello.

Two vital pieces of pediatric insurance information for those of you who aren’t PEDCOUNCIL members or on the SOAPM mailing list.

Item 1:

UHC moves to enhance immunization administration payments
After receiving input from the AAP regarding low immunization administration pricing, UnitedHealthcare (UHC) found the main reason for this is that pediatricians are on contracts with fee schedules tied to 2004 CMS Medicare rates or prior years. UHC reported that, to a lesser extent, it also found that some markets set immunization administration pricing at a lower percentage of the CMS Medicare rates. Most markets are currently using 2008 CMS for physician contracting. UHC has identified those pediatricians whose contracts with fee schedules set at or prior to the 2004 CMS Medicare rates and will be working over the next several months to update the fee schedules and migrate those impacted to a more current CMS year in order to increase immunization administration pricing.

UHC will provide written notice of the fee schedule changes for immunization administration codes in conjunction with other fee schedule maintenance in some cases per the terms of the contract. UHC expects that this initiative will take several months in order to complete financial analysis, complete the revised contracts and mail to physicians, load the new rates and provide the appropriate notice per the contract.
The AAP will continue to dialogue with UHC regarding the timing of the effective dates of the updated fee schedules and to monitor UHC review of its vaccine payment methodology.

Item 2:

As follow-up to a recent meeting with the AAP, Humana has announced that it will revise its pediatric immunization payments, as well as pay for telephone care.

Vaccine payments: As of October 1, 2008, Humana will increase payment for pediatric immunizations that will based on a percent of the current average sales price (ASP). Humana will also reimburse vaccines that are not based on ASP to a percent of average wholesale price (AWP).  Details regarding reimbursement on the Humana National Drug and Biologicals Fee Schedule can be viewed by participating providers via the secure area of www.Humana.com ( http://www.humana.com/ ) In addition, for pediatric combination vaccines containing four or more vaccine components, Humana will pay the immunization rate plus an additional $11 to the allowable fee. This would not apply to those combination vaccines with fewer than four vaccine components (e.g., MMR
and DTaP).

This reimbursement methodology applies only to providers that have either received written notification or signed an addendum indicating transition to the Humana National Drug and Biologicals Fee Schedule.  For more information regarding the transition to the national drug schedule, please contact the Humana contracting representative in your market.

Telephone care: Humana has established processing rules for the new telephone CPT codes 99441-99443. these codes will be processed as covered services; however, the and the plan member will be responsible for standard office co-payments or other cost-share amounts applicable to any other office visit. Medicare does not cover those telephone consultation codes nor does the Department of Defense (TRICARE) so neither Humana Military Healthcare Services (HMHS) nor Humana Medicare will cover the telephone care codes. Only Humana commercial health plans will provide payment for telephone care. Payment for the telephone consultation codes will be based upon the current RBRVS system.

For information on coding and billing for telephone care, see the AAP Payment for Telephone Care Toolkit, available on the PMO at:  http://practice.aap.org/telecarepmt.aspx

AAP private payer advocacy will continue to work with Humana and shareadditional details of these payment enhancements.

A lot to comment about.

• First, about UHC. Rather, I should say, “It’s about time, UHC.”  Although I suspect their excuse is, technically, true, it’s totally bogus for them to pretend that they didn’t realize what is going on.  Sure, this is good news and I applaud the AAP for keeping up the fight.  But ask yourselves this: if so many of these pediatricians are tied to 2004 (before the big imms admin jump), how did UHC calculate the values of the 90465 and 90466 which did not exist in 2005 and never existed with the lower RVU rates? Obviously, UHC made a deliberate decision to lock peds into 2004 during their big push to get everyone on RVU-based schedules, because it saved them millions of of dollars. DUH.
• Whoa, Humana.  A couple things:
  • ASP!  Finally!  Someone using data that’s at lease close to what the pediatricians pay.  Crazy talk.
  • Even crazier: Humana will pay extra - and decently extra - for combo vaccines with 4 or more components?  <thunk> I just passed out.  Sure, the imms admins are rolling towards counting antigens anyway, but Bravo Humana! for doing the right thing in the first place.  There is no longer an incentive for docs to avoid the combo vaccines (children throughout the country rejoice).  Good medicine.  Who made this sensible decision and, as a result, should fear for his or her job security?
  • Craziest: Humana pays for telephone care. I broke the boldface out for that line and went back and highlighted other things as a result.  What has gotten into these people?!  [I mean that in a good - no, great - way.]  It’s official - a national payer will cover telephone codes.  Awesome.

Honestly, I am going to tell all my friends to choose Human if they can.  Not because these dollars make some huge difference, but because it’s a sign that someone in that company gets it and they should be applauded.

More tomorrow, perhaps “live” from the coding conference!