According to the timeline that MCAG has proposed, all documents and depositions should be gathered and completed by later this summer, with a cumulative hearing in the fall. Arbitrator Schultz gives all indications that he is very engaged in the proceedings, and shares our interest in resolving the arbitration as quickly and efficiently as possible.

Although major updates are not likely until, perhaps, this summer, there will likely be several hearings and discussions over the next few months. Thank you for your continued patience. We realize that the process has been, and continues to be, painfully slow, but MCAG is encouraged that this next round of hearings will propel this matter towards resolution.

Although MCAG has been fighting for claims to be paid under the CIGNA Settlement for the past seven years, we are cautiously optimistic that there will be positive movement forward in the near future.

MCAG certainly understands and shares Class Member frustration with the delays imposed thus far, but please rest assured that resolving the CIGNA Settlement satisfactorily for our Class Member clients remains a priority.

In the meantime, please feel free to contact a MCAG representative if you have any questions, or if we can be of any further assistance.

The AMA and the Medical Society of the State of New York, the Missouri State Medical Association and others alleged that Defendants provided insufficient reimbursement for Covered Out of Network (OON) Services or Supplies by using flawed databases (the Ingenix Databases) that understated the Usual Customary and Reasonable allowance. In addition to this cash payment, the settlement also provides for the elimination of the Ingenix data base and the establishment of the FAIR Health database to create transparency in the calculation and allowance of payments based on Usual Customary and Reasonable (UCR) allowance. Visit www.ama-assn.org/go/litigationcenter for more information about the UHC Class Action and Settlement.

Claims sent through the Managed Care Advisory Group (MCAG)
Most physicians will receive checks from the Managed Care Advisory Group (MCAG) in the next couple of months, but if you have not received your check by April 15, 2012 and filed through MCAG, you should contact MCAG to inquire about the status of your settlement check by:

• Toll-free phone: (800) 355-0466 – press option 4
• E-mail: physicianservices@mcaginc.com

Update your MCAG record
Physicians who filed claims and have moved since filing should provide their updated mailing address as soon as possible to ensure the timely delivery of their checks.
AMA membership also offered its members an opportunity for an additional 15% to 20% savings on MCAG service fees based on the recovery amount obtained from the UHC Class Action. If providers have recently joined or left your practice, please contact MCAG to ensure that your active provider list is accurate. If some or all of your practice’s physicians are not already AMA members, it’s not too late to activate their AMA membership in order to fully leverage your potential savings in the UHC Settlement, in addition to the other AMA membership benefits. Visit www.ama-assn.org/go/join today.

Hold health insurers accountable
Although it is too late to file a claim for damages from this settlement fund, physicians who would like to hold health insurers accountable regarding out-of-network issues may wish to visit www.ama-assn.org/go/psatoolkits to access the Out-of-Network toolkit, which contains detailed information that physician practices can use in their non-contracted dealings with insurers.

• Blue Cross Blue Shield of Michigan Asks Federal Court to Dismiss Government Antitrust Lawsuit (via PR News Wire): MCAG will continue to monitor this case as it has the potential to dramatically impact the control Health Insurers maintain over the marketplace. While BCBS Michigan is correct in citing their longstanding protections against federal antitrust proceedings, they are facing off against the government in a case where they may have taken clear action that violates anti-competitive business rules.
• How Release-of-Information Outsourcing Can Curb Economic Risk (via Health Leaders Media): This kind of pressure will only increase as the move to EMR/EHR systems becomes a higher priority. Protecting your business from HIPAA violations, RAC audits focusing on documentation errors and the critical process of properly implementing EMR/EHR systems are all part of the MCAG solution that we are working on for 2011.
• Uncertainty prompts doctors to rethink private practice, according to survey (via AMA): For the past decade providers have struggled with the back and forth between health systems and hospitals buying private practices and then reselling them. These changeovers can actually lead to more lost revenue in the transition. Proper management of payer relationships and ensuring correct payment will always be maintained through the MCAG Claim Analysis and Recovery Solution. Remember to protect yourself and get all you have earned – regardless of whose name is on the letterhead.
• Hospitals integrating their medical devices and EMRs (via AMA): “A third of hospitals have integration between medical devices and electronic medical records, allowing data recorded on the devices to be uploaded automatically into EMRs, according to a survey released Dec. 1 by HIMSS Analytics…”
• HITECH Compliance Is About Business Process, Not Technology (via Physicians News): “For years, HIPAA insisted on data privacy and security protections—and for years, those same requirements were ignored with relative impunity.  Last year’s HITECH act changes all that. But as the manufacturing sector learned a decade ago in the series of debacles that accompanied migrating to ERP systems, complex systems management needs to make business process refinement the primary focus…”
• HITECH, HIPAA Rules to Launch Simultaneously in 2011 (via Health Leaders Media):  With HITECH poised to have such a dramatic impact on the business process it becomes even more critical that you ensure it is done in a way that both meets government requirements and helps your business continue to move forward. MCAG will be offering clients comprehensive solutions in the realm of EMR/EHR tools and meaningful use validation.

• Is Aetna, Medicity deal the beginning of the end for independent HIE vendors? (via Fierce Health IT): While Aetna’s $500 million acquisition of health information exchange vendor Medicity this week appears to be a direct reaction to UnitedHealth Group’s deal for Axolotl earlier this year, the move is much bigger than one-upsmanship, and likely will start a ripple effect that will end with independent HIE vendors going the way of the dinosaur, writes Chilmark Research blogger John Moore…
• Rapidly Evolving Physician-Payment Policy — More Than the SGR (via NEJM): Since 2002, the physician-payment policy that has been closest to home for practicing physicians has involved repeated down-to-the-wire congressional interventions to avert large Medicare payment rate cuts specified by the sustainable growth rate (SGR) formula. Less visible, but potentially as important or more important over the longer term, has been a series of steps to revamp the resource-based relative-value scale (RBRVS) underpinning the Medicare Physician Fee Schedule (MPFS), with the goal of more accurately reflecting the relative costs of providing different physician services. The recently enacted health care reform law, known as the Patient Protection and Affordable Care Act (ACA), reinforced efforts to revamp the physician fee schedule and authorized initiatives to explore broader payment reforms such as accountable care organizations and bundled payments…
• Privacy protections tested (via Modern Healthcare): Is the primary federal privacy law up to the task of protecting patient information in the 21st century? It’s a question we put to opinion leaders in the legal, research, policy, ethics, provider and technology fields within the healthcare privacy community. It comes as hospitals and office-based physicians ramp up adoption of electronic health-record systems and join information exchanges to qualify for their share of the $27 billion in federal information technology subsidy payments available under the American Recovery and Reinvestment Act of 2009, also known as the stimulus law…
• Letters to CMS note government’s own barriers to ACO adoption (via Modern Healthcare): While some segments of the federal government want to encourage cooperation among healthcare providers through the formation of accountable care organizations, others arms of the government punish hospitals for pursuing the same kinds of activities, the American Hospital Association says. As a result, many of the barriers to wider adoption of the ACO delivery model exist within the federal government’s own regulations, despite the emphasis on accountable care contained in the Patient Protection and Affordable Care Act, the Chicago-based trade association said…

• AMA wants safe harbor regarding ACOs (via Modern Healthcare): The American Medical Association called for an explicit exemption, or safe harbor, from antitrust laws for accountable care organizations, a payment model that could create closer financial ties between hospitals and independent doctors…
• Crisis Communication During A Data Breach: 5 Best Practices (via Becker’s Hospital Review): A healthcare data breach can prove costly to an organization’s bottom line and its reputation. Here are five best practices for crisis communication during a breach…
• Federal Advisors Get Advice on EFT/ERA (via Health Data Management): The Affordable Care Act mandates creation and adoption of “operating rules” to make the HIPAA administrative and financial transactions more uniform.But there are real-world realities emerging that must be taken into account as operating rules are developed, says Gwendolyn Lohse, deputy director of industry group CAQH and managing director of the group’s CORE initiative to create such rules…
• What to know when selling your practice to a hospital (via AMA): Here we go again. The pendulum is swinging toward private practices selling to hospitals or affiliated foundations. Several years ago, the phenomenon drove the market. Management companies and hospitals went on a frenzy and acquired practices at breakneck speed. Soon hospitals were dissatisfied, management companies went broke, and physician practices went private again. This time around it may be different … or not…
• McKesson Pharmacy Optimization Team Identifies Five Hospital Pharmacy Trends to Watch in 2011 (via McKesson): At the 2010 ASHP Midyear Clinical Meeting, McKesson Corporation, a FORTUNE 14 healthcare services and information technology company, announced five trends that will impact the hospital and health system pharmacy. These trends, identified by the McKesson Pharmacy Optimization® team, recognize the opportunities and challenges that hospital pharmacies nationwide will need to be aware of in 2011 to help improve financial performance, increase operational efficiency and deliver the best clinical outcomes — all in an era of changing healthcare policy, greater connectivity between healthcare providers and patients, and an increased emphasis on preventive care…

CVS Caremark is the target of a new lawsuit filed in federal court last month by a group of independent pharmacists in Texas. They claim that CVS Caremark is creating an unfair and anticompetitive environment by allegedly breaking a number of laws including the federal RICO act, trade secret misappropriation, and HIPAA.

The suit alleges that CVS and Caremark, as a result of their 2007 merger, have not established or have been circumventing a firewall between their retail pharmacy divisions and the prescription benefits manager divisions, which was a key requirement for the merger approval by the Federal Trade Commission. The suit claims that CVS Caremark instead set up a system to share and mine information across all departments in the company including the marketing department. The suit further alleges this information sharing is being used to push patients to use CVS pharmacies and physicians to prescribe CVS Caremark drugs.

“CVS Caremark traps patients and non-CVS retail pharmacies in a scheme to deny patient choice of pharmacy and to smother business competition,” said Amanda Gohlke Fields, American Pharmacies general counsel in a statement from their website. “The American Pharmacies plaintiffs say patients report being forced, via higher copayments and refusal to cover maintenance medications, to leave their pharmacy where the patient and pharmacist have a long-time professional and personal relationship. Other patients report moving to a CVS Caremark network pharmacy out of fear of losing all health insurance coverage.”

In response to the lawsuit, CVS Caremark spokeswoman Christine Cramer made the following statement: “CVS Caremark is confident that its business practices and service offerings, which are designed to reduce health care costs and expand consumer choice, are being conducted in compliance with applicable antitrust, privacy and other laws.”

This lawsuit comes on the heels of another lawsuit in 2009 in which CVS was fined $2.25 million after allegations of violating patient privacy. For more information on this lawsuit, see the following links:

• Full Complaint
• American Medical Association Article
• American Pharmacies Statement
• Health Data Management Article

• Appeals court lets West Penn lawsuit proceed (via Modern Healthcare): West Penn Allegheny Health System’s antitrust lawsuit against a rival health system and insurer Highmark will continue after an appeals court overturned a decision to throw it out. The decision by the 3rd U.S. Circuit Court of Appeals rejected an October 2009 decision to dismiss the lawsuit, which alleged the University of Pittsburgh Medical Center and Highmark conspired to protect one another from competition…
• McKesson’s Horizon Clinicals Receives ONC-ATCB Certification via Drummond Group (via McKesson): McKesson’s Horizon Clinicals ^® , the industry’s most comprehensive software suite used by clinicians, patients and healthcare executives to promote high quality, safe care, has received Complete EHR certification — deeming the software capable of enabling providers to meet the Stage 1 meaningful use measures required to qualify for funding under the American Recovery and Reinvestment Act (ARRA). Tested and certified under the Drummond Group’s Electronic Health Records Office of the National Coordinator Authorized Testing and Certification Body (ONC-ATCB) program, the EHR software is 2011/2012 compliant in accordance with the criteria adopted by the Secretary of Health and Human Services…
• California’s largest health plans are fined nearly $5 million (via LA Times): California’s seven largest health plans were fined nearly $5 million in total Monday for failing to properly pay medical claims submitted by thousands of doctors and hospitals over the last three years…
• Lawyers eager for ruling in doc-ownership case (via Modern Healthcare): Lawyers are preparing “to evaluate with the finest prism possible” the ruling U.S. District Judge Michael Schneider will issue several weeks from now after announcing on Nov. 24 that he had canceled the trial set to begin Dec. 9 in Tyler, Texas, in the lawsuit brought by Physician Hospitals of America and the Texas Spine and Joint Hospital against HHS Secretary Kathleen Sebelius over the healthcare reform act’s restrictions on physician ownership of hospitals…
• Two Emdeon Staffers Receive WEDI Distinguished Service Awards 2010 (via Emdeon): During the annual WEDI Member Meeting, awards were presented to individuals and organizations in the healthcare industry whose achievements have contributed significantly to the advancement of WEDI’s mission. WEDI is a broad-based healthcare industry coalition with a mission to provide multi-stakeholder leadership and guidance to the healthcare industry on how to use and leverage the industry’s collective technology, knowledge, expertise and information resources to improve the administrative efficiency, quality and cost effectiveness of healthcare information…
• Anthem pays California hospitals $1.6 million in claims dispute (via AMA): Anthem Blue Cross of California has agreed to pay hospitals previously denied claims as part of a settlement over a system that hospitals complained about to the state’s Dept. of Managed Health Care…

• What new insurance provisions on preventive care mean for your practice (via AMA): The health system reform law requires an increasing number of insurance plans to cover 100% of widely accepted preventive health care without co-pays or coinsurance. Experts say this will complicate collecting the appropriate patient portion. But some preparation of medical office staff combined with patient education may simplify the situation…
• Appeals Court Overturns Prescriber Data-Mining Law (via MedPage Today): A federal appeals court has ruled that a Vermont law restricting the commercial use of physician prescribing data is unconstitutional. The case involved a 2007 law that bans the sale and use of prescriber-identifiable information for marketing or promoting a drug — including drug detailing — unless a physician specifically gives his or her permission to use the information…
• Pharmaceutical Marketing and the New Social Media (via NEJM): Facebook and Twitter, the largest social media Web sites, have more than 350 million users worldwide, and surveys indicate that 60% of Americans turn first to the Internet when seeking health-related information.¹ It is therefore surprising that the pharmaceutical and medical-device industries have been slow to establish a social media presence. The drug industry allocated less than 4% of the more than $4 billion it spent on direct-to-consumer advertising to Internet outlets in 2008, and only a tiny fraction of that was for social networking sites.² In the next year, however, the proportion may change substantially…
• Pharmacists’ roles touted in accountable care organizations (via Modern Healthcare): As the National Committee for Quality Assurance ponders precisely how a well-run accountable care organization ought to function, the National Association of Chain Drug Stores is urging policymakers to remember the role of pharmacists in care coordination and cost control…
• Congress puts off cuts to doctor Medicare payments (via AP): WASHINGTON (AP) — Congress agreed Monday to a one-month delay in Medicare payment cuts to doctors, giving a short-term reprieve to a looming crisis over treatment of the nation’s elderly…
• Will Accountable Care Organizations Need a Stick as Well as a Carrot? (via The Wall Street Journal): “Accountable care organization” is the latest buzzword in health-policy circles. Encouraged by the health-overhaul law, an array of hospitals and doctor groups are exploring the idea of forming these entities. They’re supposed to provide higher-quality, more efficient care by better integrating oversight of patients and reducing unnecessary services…
• Allscripts Enterprise(TM) Electronic Health Record Receives ONC-ATCB 2011/2012 Certification as ‘Complete EHR’ (via Allscripts): Allscripts (Nasdaq: MDRX) announced today that Allscripts Enterprise EHR, Version 11.2 is 2011/2012 compliant and was certified as a Complete EHR on November 24, 2010 by the Drummond Group, an Office of the National Coordinator for Health Information Technology Authorized Testing and Certification Body (ONC-ATCB), in accordance with the eligible provider certification criteria adopted by the Secretary of Health and Human Services (HHS). Additionally, Allscripts Enterprise EHR Version 11.2 Modular is 2011/2012 compliant and was certified as an EHR Module on November 24, 2010, in accordance with the eligible provider certification criteria adopted by the Secretary of HHS…

This highlights why MCAG takes such a close look at contractual terms when working with clients involved in Claim Review and Recovery and Contract Enforcement. It is not uncommon for insurance payers to use language to ensure the best case scenarios for doing business with practices who may never realize what they are agreeing to in an industry that puts such a large emphasis on the fee schedule portion of agreements.

The MFN clause, which is included in a majority of BCBSM contracts with most major hospitals in the state, requires that BCBSM be charged no more than any other competing healthcare payer and in some cases, competing payers must be charged up to 30 to 40 percent more than BCBSM. In order to get these hospitals to buy into these agreements, BCBSM allegedly agreed to raise the minimum payment amount for BCBSM contracts which would in turn raise all other payers’ contracts even further.

“The department’s lawsuit alleges that the intent and effect of Blue Cross Blue Shield of Michigan’s MFNs is to raise hospital costs for competing health plans and reduce competition for the sale of health insurance. As a result, consumers in Michigan are paying more for their healthcare services and health insurance,” said Christine Varney, Assistant Attorney General in charge of the Department of Justice’s Antitrust Division.

A spokesperson for BCBSM denies any wrong doing. “Negotiated hospital discounts are a tool that Blue Cross uses to protect the affordability of health insurance for millions of Michiganders,” said Andrew Hetzel, BCBSM vice president for corporate communications. “…We will vigorously defend our ability to negotiate the deepest possible discounts for our members and customers with Michigan hospitals.”

MCAG recommends that you take a very close look at your payer agreements before executing any documents and, if possible, seek the opinion of an expert to review the language for any potential detrimental impact on your business.

• LA expands WellPoint lawsuit while targeting another insurer: The city attorney’s office has expanded its lawsuit against WellPoint and added HealthMarkets to their list of targets alleging the use of deceptive tactics to sell limited coverage to consumers by passing it off as comprehensive coverage. This case could potentially impact the entire industry as a whole and we’ll be watching for the outcome.
• The Unintended Consequences of $4 Generics: The $4 generic prescription program at a number of pharmacies nationwide may be helping consumers but it’s causing problems for many in the healthcare industry. Many pharmacies don’t want to bother filing a claim on a $4 prescription, which has implications across the industry. This is just another reminder that we need multiple options for managing claims to encourage cooperation on all levels.