Galvano bill takes aim at insurers

Feb 18, 2008

Bradenton Herald–Sun, Feb. 17, 2008

Doreen Degirolamo’s main job is filing insurance claims for doctors, but she says she spends most of her time fighting insurance companies instead.

Appealing insurance companies’ decisions to deny claims or to demand refunds for what they consider overpayment of claims takes most of her time.

Especially frustrating are the claims managed care plans refuse to cover years after they have paid the doctor, said Degirolamo, of Medical Billing Services in Sarasota.

"It’s called off-setting," said Degirolamo, who handles insurance claims for nine local doctors. If insurance companies don’t get the refunds from doctors, they take it out of future claims filed on behalf of other patients, she said.

Rep. Bill Galvano, R-Bradenton, has filed a managed care reform bill he said would level the playing field between insurers and doctors.

Under Florida law, managed care organizations have a 30-month "look-back" period during which they can ask for a refund on claims they believe they have overpaid.

Galvano wants to shorten that look-back period to six months.

The bill would also require managed care organizations to honor their clients’ decisions to consult out-of-network physicians.

Currently, managed care plans often refuse to directly pay an out-of-network doctor, Galvano said.

The requests are called mandatory assignment of benefits, Galvano said, and constitute a valid contract between doctor and patient.

Insurance companies balk at the idea of having to honor those contracts.

"If people can go to any provider for the same coverage, there is no incentive to go to the providers in the network," said Bob Wychulis, spokesman for Florida Association of Health Plans, a trade organization.

Roger Rollman, spokesman for UnitedHealthcare, agrees.

"It would result in higher premiums both for employers and consumers," he said.

Galvano also wants to put an end to what he calls "silent PPOs," or the selling of physicians’ names and the fees they have agreed to accept to large self-insured employers like staff leasing companies, who then offer their clients a selection of managed care plans. The insurer/employer then pays the doctor the lowest rate he will accept. This buying and selling of physicians’ names and accepted fees is done without the doctors’ knowledge, Galvano said.

That practice creates an unequal playing field because doctors are not allowed to discuss with one another the fee agreements they make with managed care plans, Galvano said. To do so, says Dr. Manuel Rodriguez, a Bradenton gastroenterologist, would be a felony under antitrust laws.

Florida Health Plans is working on a compromise with Galvano and Sen. Don Gaetz, R-Niceville, who filed a companion bill in the Florida Senate. But insurers want something in return.

"We might allow mandatory assignment but it would have to be at a set fee schedule and doctors could not bill patients the difference between what they charge and what we pay," Wychulis said.

That practice is called balance-billing.

"I think that is just another disincentive," Galvano said. "The contract is between the doctor and the patient and the insurer pays the bill. If you add an exception – no balance-billing – that would have a chilling effect."

But to allow doctors to balance-bill would defeat the mission of managed care, Wychulis said.

Galvano disagreed.

"What is happening is there are valid assignments of benefits that aren’t being honored," he said. "If the patient makes a valid assignment, the insurance company has to pay."

Wychulis and Galvano are also discussing a compromise on the look-back period for denying claims and asking for a refund.

Wychulis said the trade organization is willing to shorten the look-back period, but it wants the doctor’s six-month deadline for filing claims to be shortened, as well.

That makes no sense to Galvano who said managed care plans complain now that they don’t have enough time to handle the flow of claims.

"All of these problems are just examples of how hard it is for doctors to run a business," Galvano said.

An average practice handles upward of a dozen different insurance plans. Each has a different pay scale, different rules, different procedures, says Elaine Schneider, manager of Bradenton Cardiologists.

"Just staying on top of the changes is a full-time job and a big part of the overhead doctors pay to keep their practices open," Schneider said.

"That’s just the price of a competitive market," said Wychulis.

"No," Galvano said, "that’s just another example of how we make it more difficult for patients and doctors."

Donna Wright, health and social services reporter, can be reached at 745-7049.