Monthly Archives: June 2014

New Bill Ends No-Cause Provider Terminations

On June 26, Sen. Sherrod Brown (D-OH), Richard Blumenthal (D-CT) and Rep. Rosa DeLauro (D-CT) introduced legislation that responds to the egregious practice of health plans dropping providers, namely physician specialists, from their Medicare Advantage networks during the middle of the plan year without cause.

In a press release accompanying release of the bill, Rep. DeLauro stated, “The timing and scale of UnitedHealth Group’s provider cuts have been extremely disruptive to their Connecticut patients and put them at risk.” Rep. DeLauro added that these companies need to be held accountable and not put profits before care.

The “Medicare Advantage Participant Bill of Rights” (S. 2552/ H.R. 4998) aims to protect Medicare beneficiary access to their providers, but it would also help providers stand up against health plans. Specifically, a Medicare Advantage plan could not remove a provider from its network without cause during a plan year except in cases where there is a finding of medical negligence against a provider, if a provider violates any legal or contractual requirement, or is found to be otherwise unfit to provide services. While these exceptions on their face could still leave providers vulnerable to mid-year terminations, the bill would be subject to additional agency regulations that will hopefully establish some strong boundaries of what constitutes cause.

Under the bill, plans would be required to finalize their Medicare Advantage plan provider networks 60 days in advance of the annual enrollment period and provide enhanced notice to enrollees when a provider is removed from the plan, including the contact information of other in-network providers offering items and services that are “the same or similar” to those offered by the removed provider, and information regarding options for the individual to requires the continuation of medical treatment with the removed provider.

The bill also helps physicians appeal termination by a network by requiring the Medicare Advantage plan to provide explanation for the reason(s) why they were removed from the plan.

Time for Physicians to Register on Open Payments

Effective June 1, physicians can complete the first phase of registration that will be necessary to review and appeal information about their relationships with industry before it is made available to the public later this year.

Passed as part of the Affordable Care Act, the “Physicians Payments Sunshine Act,” now known as “Open Payments,” requires that certain manufacturers and group purchasing organizations (GPOs) report to the Centers for Medicare and Medicaid Services (CMS) information about payments or other transfers of value they’ve made to physicians or teaching hospitals. Manufacturers have begun submitting data to CMS on payments or values of transfers made to physicians and teaching hospital between August 1 and December 31, 2013. The law requires that these providers be given at least 45 days to review and challenge any inaccurate or misleading data before it is made public.

Physicians wanting to review their data must register with CMS. This registration process will occur in two phases. As the first step, physicians must register in CMS’ Enterprise Portal. To complete the process, physicians will need to register in the Open Payments System, which will open in July. Phase 2 of registration will coincide with 45-day review and dispute period. While it was always envisioned that physicians would have ample time to register within the system before the 45-day review period, implementation delays have forced a condensed timeline. Therefore, it is even more critical that physicians complete Phase 1 of the registration process now if they want sufficient time to review information that, by law, must be made public no later than September 30 of this year.

CMS will create a process by which a physician will be able to contact a manufacturer or GPO that has submitted misleading or false information in an attempt to resolve the disputed submission. If the dispute cannot be resolved, CMS will allow an additional 15 days to achieve resolution before the information is made public. If resolution is still not reached, the information will be flagged as in dispute on the public Webpage.

More information about Open Payments is available on CMS’ Website.