Thursday, June 27, 2013

Unintended consequences of NYS Early Intervention Payment Policies

We received this email from the NYS Bureau of Early Intervention today. I would like to advise providers as well as the Bureau of the potential unintended consequences of this policy
Dear Colleague:

The Bureau of Early Intervention has recently received numerous inquiries regarding agreements being sent to EIP providers by insurers or insurer clearinghouses in response to claims submitted for EIP services. The agreements ask EIP providers to accept claim amounts proposed by the insurer as payment in full from the insurer for the claim which are lower than the State-established EIP rate.

This is to advise EIP providers that providers should sign and return these agreements to insurers as requested. The agreement is specific to each claim. The interim State Fiscal Agent, McGuinness, is tracking all reimbursement from insurers to individual providers. The balance owed to EIP providers who receive a payment less than the State-established rate for EIP services from insurers will be included in Key Bank payment files and reimbursed through the escrow account.
Please note that the language in insurer payment agreements which states that the provider must accept the insurer’s payment as payment in full does not apply to payments from the escrow account. Nothing in this language prohibits payment to the provider by the municipality from the escrow account. However, it is recommended that prior to signing and returning the agreement to the insurer, providers cross out “financially responsible party” and insert “payor”. This can be hand-written on the agreement, so that the sentence in the agreement reads as follows:
“Provider agrees not to bill the patient or the payor for the difference between the Billed Charge and the Expedited Amount."
This will make it clear to the insurer that the provider will not bill either the child’s parent or the payor for the difference between the insurer’s rate and the State-established rate for the EIP service.
Please do not reply to this e-mail announcement.
Thank You.

Insurance companies will do their level-best to pay the most ridiculously low reimbursements, as is common practice. We experience some insurance companies who try to reimburse outpatient occupational and physical therapy services at the outmoded rate of $2.35 per unit. This was the Medicaid rate many years ago and this rate is still present in their fee schedules. Periodically, we have insurance companies attempt to reimburse us at this rate. When this happens, we make a concerted effort to remind the insurance company of the proper contracted rate for the therapy service and in general the reimbursement is adjusted.

When no one 'fights back' about the very low rates that are sometimes attempted, the insurance companies use this rate as a basis for determining the 'community standard.' For example, when I entered private practice there was one HMO who paid $2.25 a visit and the family had a $15.00 co-pay. It took many years of advocacy to get the HMO 'share' of that fee up to a reasonable level. The reason why that HMO 'share' languished at such a low level for years is because NO ONE FOUGHT IT. Hospitals and other community health care providers were just accepting it, and it wasn't until private practitioners started pushing back that reimbursements were brought up to a reasonable level.

I understand how some might argue that private practice raised the cost of care, but in actuality private practice and other providers finally fighting back raised the reimbursements to a level of respectability. Even under current rates that are commonly reimbursed, the reimbursements are significantly below the early intervention standards.

The fact is that changes to the NYS insurance law have dumped early intervention responsibility to the commercial carriers and this is a threat to global reimbursements if we follow a policy of just 'accepting' the amount that the insurance company wants to pay. Early Intervention providers may not think it matters to them because the County escrow funds will just make up the difference. This would be a terrible error in thinking. In reality, allowing the commercial carriers in the State to set the bar so low will suppress salaries because lower reimbursements mean lower wages for everyone (in a global sense).

I am obviously not advocating for any global effort to set fees - that is definitively NOT LEGAL and that is NOT my intent. However, I am advocating for practitioners to understand the implications of 'just accepting' what the commercial insurer pays. Practitioners (and their State Associations) should advocate for fair and reasonable reimbursements from commercial and all other carriers because this impacts everyone, directly and indirectly.

JUST BECAUSE Early Intervention providers have a 'safety net' of the County Escrow, that does not mean they should blindly accept whatever commercial carriers try to get away with. Accordingly, County administrators and lawmakers should expect that commercial carriers will attempt to play low-balling fee schedule games with the Early Intervention Program because that will be an end-around to the intent of getting some private cost-sharing that helps distribute costs for delivery of this program.

1 comment:

Audrey J. Buck, OTD, OTR/L,CHT said...

Chris, I am in total agreement. I am appalled that we are being expected by EI to accept the language and rates of the insurance companies and sign the agreements! Who knows what will happen to rates in the future if we sign the agreements? Will EI rates be lowered in the future because we have signed these agreements with the insurance companies saying we accept their rate? Perhaps it is EI who needs to be educated in regard to what we, as OT practitioners AND those of us in private practice, have gone through to insure we are being paid a fair and equitable rate in comparison to our PT counterparts. It was not so long ago...1999, that OT's lobbied and had the language of NYS insurance law changed TO INCLUDE occupational therapy as a billable service under rehabilitation. Unfortunately, HMO's are not governed by insurance laws..they are governed as a business entity..(Thank you Pres. Nixon for that in 1973).