Case Studies

 

Fighting an Unfair, Unwieldy Practice

 

Client: Maryland Chapter, American College of Emergency Physicians

 

The Issue:

 

In January 2007, the Managed Care Organization (MCO) Amerigroup issued a statement that when physicians billed for a higher level service (Level III, IV, V) with a diagnosis not included on the insurer’s auto-pay list, the physicians would be reimbursed for a lower level service (Level II). Physicians had the option of supporting the claim with medical records or submitting an appeal.

 

It quickly became apparent that the large number of down-coded claims physician billing companies began to receive after implementation of this policy were costly and administratively burdensome. Diagnoses excluded from Amerigroup’s auto-pay list were difficult to avoid, as acceptable diagnoses according to the list are limited and often arbitrary.

 

Action Taken:

 

For our client Maryland ACEP, Barbara Marx Brocato and Associates developed a multi-faceted approach to bring the stakeholders to the table.

           

·         We met with the Maryland Department of Health and Mental Hygiene (DHMH) and the Maryland Insurance Administration (MIA), and Amerigroup.

·         We provided counsel and support for emergency medical groups, practice managers, and billing companies to send formal letters of concern to DHMH.

·         We brought to bear every resource at our disposal, including the legal counsel of Frank Brocato, to make clear to stakeholders that Amerigroup’s policy was unfair and in clear violation of Maryland law.

·         We engaged key members of the legislature and had a bill (House Bill 1081 - Health Insurance - Reimbursement of Providers of Health Care Services – Claims) ready to submit should our talks prove unfruitful.

·         Armed with a legal opinion and with legislature at the ready, our negotiations were ultimately successful.

 

Results:

 

·         Amerigroup agreed to allow physician practices to use the 1995 E&M Guidelines in the claims review process if they received written notification from the practices that the 1995 guidelines were preferred. 

·         The Department of Health and Mental Hygiene retracted their original position and instructed Amerigroup that they must change their down-coding policy.

 

 

 

A Voice for Residents of Continuing Care Retirement Communities

 

Client: The Maryland Continuing Care Residents’ Association

 

The Issue:

 

When the Maryland Continuing Care Residents’ Association (MaCCRA) was first formed in 1993 and engaged Barbara Marx Brocato and Associates as its partner in government affairs, there was little in Maryland law that provided for the rights and protections of residents of continuing care retirement communities (CCRCs).

 

One critical victory since that time has been ensuring that CCRCs have a grievance procedure in place for residents to make their concerns known.

 

Action Taken:

 

Barbara Marx Brocato and Associates pushed for the successful passage of legislation in 2004, 2006, and 2008 that:

 

·         Requires a continuing care facility to establish an internal grievance procedure

·         Dictates the manner of management’s response and within what time period

·         Requires the collection and study of data pertaining to resident grievances

 

Results:

 

This essential resident right:

·         Shifts the paradigm of subscriber/provider interaction and provides better balance to this important relationship 

·         Allows the CCRC resident more power and more opportunity for his or her financial or quality of life concerns to be addressed

·         Has made management more responsive to legitimate resident concerns

·         Opens a channel for officially addressing grievances so that they do not result in costly, time-consuming lawsuits