American College of Physicians: Internal Medicine — Doctors for Adults ®

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Trouble with health plans? Report problems online

From the July-August ACP Observer, copyright 2003 by the American College of Physicians.

By Brett Baker

Q: How can I report complaints about health plans?

A: College members can use the AMA's online health plan complaint form to report administrative and payment problems they encounter in their day-to-day interactions with health plans. (The form is online.)

The AMA developed and maintains the complaint form at the College's request. In 2001, the AMA's House of Delegates adopted an ACP resolution directing the AMA to establish an electronic information clearinghouse to compile and catalog physicians' administrative disputes with third-party payers.

Physicians or their staff members can submit a complaint online by logging onto the system using their AMA "members-only" password, their medical education number and date of birth, or an AMA Internet identification number (a new security feature on the AMA's Web site). They can also print out the form and fax or mail it to the AMA.

Q: What kinds of information do I need to complete the form?

A: The form requires you to identify the health plan, the type of plan product (an HMO or PPO, for example), and the type of complaint. You need to provide only limited personal information to use the form.

The AMA asks only for information it needs to determine whether complaints follow a pattern according to geographic location or practice characteristics. It will compile the data securely and confidentially and will not include physician names in any of the reports it generates.

(For more information, see the AMA's privacy statement.)

The form uses a simple check-box format. Below are some of the options included in the list of possible complaints:

  • denial of referral;

  • failure to follow general Current Procedural Terminology (CPT) guidelines;

  • denial of CPT modifier;

  • telephone hassle;

  • claim lost by health plan;

  • extensive documentation request;

  • downcoding of service;

  • inappropriate bundling of payment for services; and

  • late payment.

The form gives you space to describe the problem in greater detail. Here's an example of a common payer problem that you should report:

You performed a midlevel office visit with an established patient and removed impacted cerumen from the patient's ears on the same day. Although you correctly billed the visit as CPT 69210 (removal of impacted cerumen, one or both ears) and CPT 99213 (established patient office visit performed on the same date), the health plan bundled payment for the cerumen removal into the evaluation and management service.

In this case, you would check the boxes "failure to follow general CPT guidelines" and "inappropriate bundling of payment for services." You could also describe the scenario in the description box.

Q: Does the AMA share complaint data with ACP?

A: Twice a year, the AMA gives ACP data on complaints submitted by internists. The College uses these data to identify trends and facilitate discussions with national health plans to resolve the administrative hassles and complaints that internists encounter with payers. ACP also uses these data to promote legislative and regulatory changes that address the problems members are having.

Q: Can I continue to send complaints about health plans directly to ACP?

A: Yes. ACP encourages you to report your problems with health plans directly to the College in addition to documenting them through the AMA's online process. Once you file a complaint on the AMA form, please send information about your administrative dispute to me at bbaker@acponline.org.

While the complaint form enables the College to analyze trends and follow up with health plans, ACP needs to hear directly from individual College members who encounter problems with payers to promptly advocate on their behalf.

For more on the College's efforts to reduce hassles from third-party payers, see "How the College is working to reduce the hassle factor."

Brett Baker is a third-party payment specialist in the College's Washington office.

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