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How ACP is working to reduce administrative hassles

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

By John DuMoulin

While this column generally focuses on legislative issues, ACP puts as much effort into advocating for regulatory improvements in health plan rules as it does into lobbying Congress.

The goal of these efforts is simple: to reduce the insurance hassles that unnecessarily limit internists' ability to provide patient care. Members constantly tell us that payers' bureaucratic requirements take a heavy toll on physician morale. Complex rules and procedures also make internal medicine far less attractive to medical students choosing a specialty.

Insurers may have sound reasons for creating policies and procedures, but they often implement rules in ways that waste physicians' time and create discontinuities in patient care. Physicians are particularly concerned about how these policies fundamentally alter the traditional physician-patient relationship.

Sadly, the number of administrative hassles and complex payer rules has only increased over the past 15 years. ACP's 1998 policy paper on insurer hassles found the following:

  • Physicians are spending more time on insurance paperwork and less time seeing patients.

  • Physicians believe that insurers question their professional judgment too often.

  • Physicians have been forced to hire additional personnel to keep up with the onerous paperwork mandated by insurers.

If legislators and insurers do not reduce administrative hassles in the near future, the College believes that patient access to fundamental health care services will suffer, with long-lasting consequences for future generations of Americans.

ACP's victories

Beginning in 2000, ACP began analyzing insurer hassle issues and voicing concerns about them to more than 500 insurers across the country. Here are some recent victories that resulted from College advocacy:

  • Medicare will publish its correct coding initiative edits on the Internet so physicians can easily search the rules. Physicians currently have to purchase the information from the government for more than $300 a year. (See "Medicare to put coding information on Web for free.")

  • Medicare simplified its documentation requirements for teaching physicians.

  • Medicare simplified its glucose monitoring supply certification policy for diabetic patients.

  • The Current Procedural Terminology (CPT) editorial panel simplified the definitions of evaluation and management codes. The panel is also in the process of creating clinical examples to help physicians understand the codes for CPT 2005.

  • URAC, a health care accrediting agency, developed claims processing standards for insurance companies seeking accreditation.

  • URAC also incorporated standards opposing "silent" PPO discounts so that insurers do not discount fees without physicians' approval.

  • The AMA developed a health plan complaint form to report the administrative and payment problems that physicians encounter in their day-to-day interaction with health plans. The AMA—which developed the form at the request of the College—compiles and catalogs internists' complaints, sharing those data with ACP. (For more information, see "Trouble with health plans? Report problems online.")

Future fights

While we're proud of the progress we've made, the fight is far from over. Many administrative requirements continue to waste valuable time physicians could be spending with patients.

Our current and continuing advocacy efforts focus on eliminating unfair rules and simplifying administrative tasks by developing uniform standards for the insurance industry. Here's an overview of projects in the works to reduce hassles:

  • All-products clauses. For years, members have complained about "all-products" clauses that some insurers include in their physician participation contracts. In order to join a provider network, some insurers use all-products clauses to force physicians to accept all the products they offer or plan to offer. In areas with only a handful of insurers, this all-or-nothing language forces physicians to accept meager products.

    All-products clauses essentially restrict physicians' ability to close their patient panel to certain insurance products. Without a way to manage the volume of patients in their practices, physicians believe the quality of patient care will suffer and their practices' financial viability will be jeopardized.

    For a long time, insurers argued that physicians disliked these clauses because they wanted to "cherry pick" patients with the most favorable payment terms. Through consistent discussions with the insurance industry, however, ACP has convinced insurers that physicians are more concerned about the effects on quality of care than on payment.

  • Eligibility data. Physician offices need easily accessible eligibility data to determine if a patient is currently enrolled in a health plan and what his or her co-pay should be.

    ACP has advocated for insurers to create subscriber databases so that physician offices can check eligibility information simply by entering a patient's identification number into a secure Web site. In recent years, several insurers have taken this step.

    ACP is now working with the Council for Affordable Quality Healthcare (CAQH), a coalition of major insurers with more than 100 million subscribers, to develop a single electronic platform to check on patient eligibility.

  • Credentialing. For more than five years, ACP has advocated for a single health insurance industry standard for credentialing, recredentialing and site visits. ACP has worked with CAQH to create a universal credentialing system. The system is now available in 13 states and will soon become available nationwide.

    With the universal system, physicians have to be credentialed only once. The physician's office will periodically review the insurer's credentialing information and verify its accuracy. With the physician's approval, insurers should be able to share credentialing and site visit information.

  • Drug formularies. Physicians say formularies are often difficult to follow because they vary from plan to plan and change frequently. In addition, some formularies include burdensome rules and stipulate how often a new prescription must be written. Some also restrict the quantities of drugs that patients with chronic conditions can order at one time.

    ACP believes that most prescription hassles could be eliminated by switching to electronic prescribing. Physicians could check electronic formularies when they write prescriptions and make any necessary changes on the spot.

    ACP is working with CAQH to address this issue.

  • Standardized forms. ACP is working with insurers to develop standardized forms (a single referral form, for example) so physicians don't have to fill out different paperwork for every insurer. Uniformity would reduce the amount of time staff currently spend learning an array of forms, gathering information and completing paperwork.

    ACP believes that implementing these administrative simplification solutions will go a long way toward improving the practice environment. Even more importantly, it will allow physicians to dedicate more time to patient care.

John DuMoulin is Director of Regulatory and Insurer Affairs in the College's Washington office.

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