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Health Insurance Companies Fined $940 Million for Failing to Reimburse Physicians

June 24, 2012 Leave a comment
Health insurance companies  routinely do not reimburse physicians on purpose in order to protect company profits. This problem has skyrocketed over the past decade alone. During this particular time period, One hundred nine companies were fined $940,445,363 for failing to pay physicians in a timely manner.  States gave 104 companies 455 fines totaling $156,951,581.   Forty four are non-profit and they were fined 170 times totaling $62,030,981.  Sixty five are for-profit and they were fined 285 times totaling $94,920,600.  Ten for-profit companies had federal ERISA settlements against them which totaled $784,855,000. Blue Cross Blue Shield had the most fines of the non-profit sector which totaled $54,645,878. UnitedHealthcare was fined the most of the for-profit sector which totaled $417,514,675.
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Not-for-Profit
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Affinity
# of State Fines:   5
Total State Fines:  $30,900  (Source 1
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Alameda Alliance
# of State Fines:    1
Total State Fines:  $333,229    (Source 1
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Blue Cross Blue Shield
# of Fines:   43
Total State Fines:  $54,645,878  (Source 1
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Capital District Health Plan
# of State Fines:    6
Total State Fines: $55,700  (Source 1
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Centercare
# of State Fines:  3
Total State Fines: $8,200  (Source 1
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Community Choice
# of State Fines:  2
Total State Fines:  $10,300   (Source 1
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Community First Health Plans
# of State Fines:    1
Total State Fines:  $200,000    (Source 1
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Community Health Plans of NY, Washington
# of State Fines:    4
Total State Fines:  $1,005,200  (Source 1
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Community Premier Plus
# of State Fines:    1
Total State Fines:  $1,200    (Source 1
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Fidelis
# of State Fines:    5
Total State Fines:  $10,100  (Source 1
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FreeState
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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HM Health Insurance
# of State Fines:   1
Total State Fines:  $500 (Source 1
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Group Health Cooperative
# of State Fines:    15
Total State Fines:  $57,050 (Source 1
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Health Services Med Corp
# of State Fines:    1
Total State Fines:  $7,300 (Source 1
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Healthcare Underwriters Mutual
# of State Fines:    1
Total State Fines:  $9,750  (Source 1
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HealthNow (Medicare Advantage)
# of State Fines:    12
Total State Fines:  $1,170,300 (Source 1
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Health Plus
# of State Fines:    3
Total State Fines:  $75,200  (Source 1
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Healthsource plan of NY/NJ
# of State Fines:    2
Total State Fines:  2,200 (Source 1
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Heritage Provider Network
# of State Fines:    2
Total State Fines:  $294,000  (Source 1
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HM Health Insurance
# of State Fines:   1
Total State Fines:  $500 (Source 1
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Hometown Health Plan
# of State Fines:    1
Total State Fines:   $25,000 (Source 1
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Indemnity Insurance Company
# of State Fines:    1
Total State Fines:  $1,800 (Source 1
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Independent Health Association
# of State Fines:   5
Total State Fines:  $49,775 (Source 1
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Inland Empire
# of State Fines:    1
Total State Fines:  $2,500  (Source 1
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Inter Valley
# of State Fines:    1
Total State Fines: $7,500   (Source 1
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JMH Health Plan
# of State Fines:    1
Total State Fines:  $25,000 (Source 1
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Kaiser Foundation Health Plans
# of State Fines:    13
Total State Fines:  $792,800 (Source 1
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Lifewise Health Plan
# of State Fines:    1
Total State Fines:  $1,250 (Source 1
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Managed Health Network
# of State Fines:    2
Total State Fines:  90,000  (Source 1
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Mayo Health Plan
# of State Fines:    1
Total State Fines: $25,000  (Source 1
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Med Mutual of Ohio
# of State Fines:    1
Total State Fines:  $100,000 (Source 1
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Mercy Health Plans
# of State Fines:    1
Total State Fines:  $100,600 (Source 1
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Molina
# of State Fines:    1
Total State Fines:  $5,000 (Source 1
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MVP Health Plan
# of State Fines:    3
Total State Fines: $35,000  (Source 1
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Promina Health Plan
# of State Fines:    1
Total State Fines: $81,635  (Source 1
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Providence Health Plan
# of State Fines:    2
Total State Fines:  $3,750 (Source 1
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Sharp Health Plan
# of State Fines:    1
Total State Fines:  $20,000  (Source 1
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Sloans Lake
# of State Fines:    1
Total State Fines:  $156,750 (Source 1
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St. Barnabus (Partners in Health)
# of State Fines:    1
Total State Fines:   $1,300 (Source 1
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St. Joseph’s Care Management
# of State Fines:    1
Total State Fines:  $33,538 (Source 1
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SummaCare
# of State Fines:    1
Total State Fines:   $125,000 (Source 1
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Unicare Life
# of State Fines:    6
Total State Fines:  $1,533,426 (Source 1
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Univera / Health Plan Inc (NY)     NP
# of State Fines:    2
Total State Fines:  $24,550 (Source 1
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Vytra
# of State Fines:   9
Total State Fines:  $483,800 (Source 1
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For-Profit
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Aetna  (Public Traded)
# of  State Fines:     31
Total State Fines:  $8,262,982  (Source 1
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American Heritage Life (AllState, Publicly Traded)
# of State Fines:  2
Total State Fines: Fined $264,765  (Source 1
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American Medical Life
# of State Fines:     1
Total State Fines $1,000       (Source 1
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Amil International Insurance Company
# of State Fines:   2
Total State Fines  $196,543  (Source 1
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Alta Health and Life
# of State Fines    1
Total State Fines: $250  (Source 1
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Avemco Insurance
# of State Fines:   2
Total State Fines: $269, 729  (Source 1
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Beacon Health Plan
# of State Fines: 1
Total State Fines: $50,000    (Source 1
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Capitol American Life
ERISA Settlement:  $6,826,000 (Source 6
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Careplus
# of State Fines: 4
Total State Fines:  $28,345  (Source 1
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Central Reserve Life
# of State Fines:  2
Total State Fines:   $811,513 (Source 1
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CHA HMO
# of State Fines:  1
Total State Fines:  $43,750   (Source 1
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Cigna (Publicly Traded)
# of State Fines:    26
Total State Fines:  $4,954,534 (Source 1
ERISA Settlement:  $954,000  (Source 6
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Combined Insurance Company of America of Illinois
# of State Fines:  1
Total State Fines:  $30,000   (Source 1
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Conseco Medical Insurance Company
# of State Fines:    3
Total State Fines:    $1,820,610  (Source 1
ERISA Settlement: $9,975,000   (Source 6
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Continental Assurance
# of State Fines:    3
Total State Fines:   $161,212   (Source 1
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Coventry
# of State Fines:  1
Total State Fines:  $10,000  (Source 1
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CVS
ERISA Settlement: $3,000,000  (Source 6
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Dental Benefit Providers Maryland
# of State Fines:    2
Total State Fines:   $80,000  (Source 1
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Excellus
# of State Fines:    8
Total State Fines:   $36,400  (Source 1
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Florida 1st Health Plan
# of State Fines:    1
Total State Fines:  $25,000  (Source 1
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Fortis Insurance
# of State Fines:   3
Total State Fines:  $1,410,055  (Source 1
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Foundation Health
# of State Fines:    1
Total State Fines:  $50,000 (Source 1
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FreeState
# of State Fines:    1
Total State Fines:   $75,000 (Source 1
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Great West Healthcare
# of State Fines:    4
Total State Fines:  $2,323,669  (Source 1
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Guardian Life
# of State Fines:    6
Total State Fines:  $1,440,305 (Source 1
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Hartford Casualty Insurance Company
# of State Fines:    1
Total State Fines:  $20,000  (Source 1
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Health Care Plan of NY
# of State Fines:    1
Total State Fines:   $20,500 (Source 1
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Health Insurance Plan of NY
# of State Fines:    10
Total State Fines:  $351,350 (Source 1
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Health Net
# of State Fines:    9
Total State Fines:  $521,700 (Source 1
ERISA Settlement: $215,000,000  (Source 6)
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Health Options
# of State Fines:    1
Total State Fines:  $50,000  (Source 1
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Healthplan Southeast
# of State Fines:    1
Total State Fines: $50,000   (Source 1
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HMO Colorado
# of State Fines:  1
Total State Fines:  $252,500  (Source 1
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Human Affairs
# of State Fines:    1
Total State Fines:  $5,500 (Source 1
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Humana (Publicly Traded)
# of State Fines:    9
Total State Fines:  $2,879,113 (Source 1
ERISA Settlement:  $58,000,000  (Source 8
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LifeGuard
# of State Fines:    1
Total State Fines:  $40,000 (Source 1
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Magellan
# of State Fines:    2
Total State Fines:  $450,000 (Source 1
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Meco Health Solutions
ERISA Settlement: $42.5 million
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Med Insurance Company of Ohio
# of State Fines:    1
Total State Fines:  $60,000 (Source 1
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Mega Life and Health Insurance Company
# of State Fines:    3
Total State Fines:  $875,000  (Source 1
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MetLife Insurance Company
# of State Fines:   5
Total State Fines: $1,343,428  (Source 1
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MDNY
# of State Fines:    9
Total State Fines:  $185,650  (Source 1
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Merit  Behavioral
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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Mid-South Insurance Company
# of State Fines:  1
Total State Fines:  $51,850 (Source 1
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Mid-West National Life
# of State Fines:    2
Total State Fines:  $140,500  (Source 1
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New England Life
# of State Fines:    1
Total State Fines:  $41,500 (Source 1
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New York Life Insurance
ERISA Settlement: $14,000,000  (Source 6)
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NYL Care
# of State Fines:   5
Total State Fines:  $1,092,050 (Source 1
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Oriska Insurance
# of State Fines:    1
Total State Fines:  $3,900 (Source 1
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Oxford Health Plans
# of State Fines:    13
Total State Fines:  $5,046,674 (Source 1
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Pacific Life and Annuity Company
# of State Fines:    3
Total State Fines: $3,530,579  (Source 1
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Physicians Healthcare Plans
# of State Fines:    2
Total State Fines:  $78,300 (Source 1
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Principal Life Insurance Company
# of State Fines:    2
Total State Fines:  $704,856 (Source 1
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Protective Life Insurance Company
# of State Fines:    2
Total State Fines:  $152,780 (Source 1
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Prudential
# of State Fines:    6
Total State Fines:  $216,000  (Source 1
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Qualmed Washington
# of State Fines:    1
Total State Fines:  $250,000 (Source 1
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Renaissance Health and Life
# of State Fines:   1
Total State Fines:  $1,750 (Source 1
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Rite Aid
ERISA Settlement: $67,600,000 (Source 6)
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Safeguard Health Plans
# of State Fines:    3
Total State Fines:  $239,339 (Source 1
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Sierra Health / Texas Health Choice Companies
# of State Fines:    3
Total State Fines:  $1,437,450 (Source 1
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Systemas Medicos
# of State Fines:    1
Total State Fines:  $7,500  (Source 1
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Trustmark Insurance Company
# of State Fines:    2
Total State Fines: $595,676  (Source 1
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United American Insurance Company of McKinney
# of State Fines:   1
Total State Fines:   $190,000 (Source 1
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United Healthcare
# of State Fines:    59
Total State Fines:  $50,514,675  (Source 1, 2, 3,4, 5
ERISA Settlement: $17,000,000 (Source 6
ERISA Settlement: $350,000,000 (Source 7
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Vista Health Plan
# of State Fines:    1
Total State Fines:  $50,000 (Source 1
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Well Care
# of State Fines:    6
Total State Fines:  $147,100 (Source 1
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 Sources:
2. http://americustimesrecorder.com/local/local_story_%20003234020.html
3. www.texmed.org/Template.aspx?id=6325
4. http://www.newsobserver%20.com/news/stor%20y/1152663.html
5. http://azstarnet.com/all-headlines/119565/
6. http://www.erisasettlements.com/press/ERISA-Chart.pdf

7. http://www.healthdatamanagement.com/news/ama-unitedhealth-insurance-lawsuit-ingenix-database-43997-1.html

8. http://www.bizjournals.com/milwaukee/stories/2005/10/17/daily14.html?from_rss=

U.S. Congress Working to Replace Physician Sustainable Growth Rate

May 17, 2012 Leave a comment

The U.S. Congress is currently working on legislation to replace the physician sustainable growth rate. Since 2002, this has become a highly debated topic in Congress that has resulted in 14 CRs (short-term measure) being passed that were aimed to delay a 30% cut to physician Medicare payments. H.R. 5707 introduced and aimed at replacing the SGR.

To get things started, The U.S. Senate Finance Committee held a roundtable discussion on the matter last week. You can view the discussion at http://www.finance.senate.gov/hearings/hearing/?id=ce954372-5056-a032-5269-10f65a59f5d4. In a statement, Chairman Max Baucus (D-MT) said : “Medicare’s sustainable growth rate (SGR) formula has not worked as planned. The annual cuts the formula calls for have snowballed the problem.” Ranking member Orrin Hatch (R-UT) said in a statement: “We must provide a stable foundation for paying physicians today, not five or 10 years from now.”

On May 9, a billed aimed at replacing the SGR was introduced. H.R. 5707: Medicare Physician Payment Innovation Act of 2012 was officially introduced in the House by members Allyson Schwartz (D-PA, former hospital CEO) and Dr. Joe Heck ,DO (R-NV, physician). The bill can be read here: http://www.gpo.gov/fdsys/pkg/BILLS-112hr5707ih/pdf/BILLS-112hr5707ih.pdf. In order for the bill to be successful, it will need to have FULL support by all of the physicians in Congress. The physicians that need to be encouraged to pass it are: John Barrasso (R-WY), Tom Coburn (R-OK), Rand Paul (R-KY), Dan Benishek (R-MI), John Boustany (R-LA), Paul Broun (R-GA), Michael Burgess (R-TX), Larry Buschon (R-IN), Bill Cassidy (R-LA), Scott DesJarlais (R-TN), John Fleming (R-LA), Phil Gingrey (R-GA), Paul Gosar (R-AZ), Andy Harris (R-MD), Nan Hayworth (R-NY), Ron Paul (R-TX), Tom Price (R-GA), Phil Roe (R-TN), Donna Christensen (D-VI), and Jim McDermott (D-WA).

Stay tuned to this blog for further updates on this story.

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Sources:

http://www.finance.senate.gov/hearings/hearing/?id=ce954372-5056-a032-5269-10f65a59f5d4

http://www.finance.senate.gov/imo/media/doc/05102012_Baucus_Roundtable_Statement_Regarding_the_Medicare_Physician_Payment_System%5b1%5d.pdf

http://www.finance.senate.gov/imo/media/doc/05%2010%2012%20Hatch%20Opening%20Statement%20for%20SGR%20Roundtable.pdf

http://www.gpo.gov/fdsys/pkg/BILLS-112hr5707ih/pdf/BILLS-112hr5707ih.pdf

Physicians Say NO to Accountable Care Organizations

May 7, 2012 Leave a comment

Physicians in large numbers are rejecting Accountable Care Organizations (ACO). According to a survey by MedScape, physicians believe that these type of organizations are way to risky and are very vulnerable to being defrauded by insurance companies (evidence of insurance companies defrauding Medicare coming in next blog post). MedScape had 3,200 physicians respond to their survey and they came up with the following results:

5% of physicians want to be involved in an ACO

42% say physician alignment is impossible and is primary reason for not moving forward with ACO development

50% believe ACO federal guidelines will have a negative impact on patient care

52% say their income will be dramatically reduced

67% say they will not reduce the amounts of tests and procedures they order in order to comply with federal ACO guidelines

As you can see, there is a very large amount of physician resistance when it comes to ACOs.  In order for the ACOs and other alternative models to be successful, physicians MUST be in support of them. Otherwise, the concept will never work.

Sources:

http://www.medscape.com/viewarticle/761870_5

http://www.fiercehealthcare.com/story/physicians-say-no-thanks-risky-acos/2012-05-04

Current Medical Professionals in The United States Congress

May 3, 2012 1 comment

Currently, there are 28 medical professionals in the United States Congress. When trying to get health policy initiative considered, they are the people who truly need to be contacted. I used to write federal healthcare policy for the U.S. Senate HELP Committee and I know the right way to reach them. I specifically help physicians contact them and I even recently helped an Internist contact and speak directly with 143 health legislative assistants ( who actually write healthcare bills), 5 members of Congress (Cooper, Conrad, Frank, Kucinich, Rangel), and two CMS officials about a new physician payment model he designed. If you are a physician and interested in learning how to best communicate with the physicians and nurses listed below, please contact me.

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Nurses in U.S. House of Representatives

Diane Black (R-TN)                                           Karen Bass (D-CA)

Ann Buerkle (R-NY)                                           Lois Capps (D-CA)

Renee Ellmers (R-NC)                                       Berniece Johnson (D-TX)

Carolyn McCarthy (D-NY)

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Physicians in U.S. Senate

John Barrasso  (R-WY)

Tom Coburn     (R-OK)

Rand Paul        (R-KY)

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Physicians in U.S. House

Dan Benishek (R-MI)                                     Donna Christensen (D-VI)

John Boustany (R-LA)                                   Jim McDermott (D-WA)

Paul Broun (R-GA)

Michael Burgess (R-TX)

Larry Bucshon (R-IN)

Bill Cassidy (R-LA)

Scott DesJarlais (R-TN)

John Fleming (R-LA)

Phil Gingrey (R-GA)

Paul Gosar (R-AZ)

Andy Harris (R-MD)

Nan Hayworth (R-NY)

Joe Heck (R-NV)

Ron Paul (R-TX)

Tom Price (R-GA)

Phil Roe (R-TN)

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Physicians in the United States Congress

December 14, 2011 1 comment

Here is an updated list of the physicians in Congress.

U.S. Senate
John Barrasso MD (R-WY)  – orthopedic surgeon
Tom Coburn MD   (R -OK)   – family practitioner
Rand Paul (R-KY)  – opthalmologist

U.S. House

Dan Benishek (R-MI) – general surgeon
John Boustany (R- LA)- cardiovascular surgeon
Paul Broun (R -GA) – family practitioner
Michael Burgess (R-TX) – OB/GYN
Larry Bushon (R-IN) – thoracic surgeon
Bill Cassidy (R-LA) – gastroenterologist
Donna Christensen (D-VI) – family practitioner
Scott DesJarlais (R-TN) – family practitioner
John Fleming (R-LA) – family practitioner
Phil Gingrey (R-GA) – OB/GYN
Paul Gosar (R- AZ) – DDS
Andy Harris (R-MD) – anesthesiologist
Nan Hayworth (R-NY) – opthalmologist
Joe Heck (R-NV) – emergency medicine
Jim McDermott (D-WA) – psychiatrist
Ron Paul (R-TX) – OB/GYN
Tom Price (R-GA) – orthopedic surgeon
Phil Roe (R-TN) – OB/GYN

American Medical Association AGAINST ICD-10 Implementation

November 16, 2011 Leave a comment

The American Medical Association have voted to fight against the implementation of ICD-10. Many major hospital systems have come out against it stating that it is too expensive to implement.

Healthcare IT News reports that the 65th Interim Meeting of the AMA in New Orleans, in fact, “the AMA House of Delegates voted to work vigorously to stop implementation of ICD-10,” primarily on the grounds that the “timing could not be worse” for this “massive and expensive undertaking” brings too little benefit to physicians, and will prove disruptive as they also work to implement EHRs and demonstrate meaningful use. Citing a 2008 study, AMA explained that projected costs of converting to the unfunded code sets mandate will cost even a three-physician practice $84,000 and slightly more than $285,000 for a 10-physician group.

Source: http://www.healthcareitnews.com/news/ama-mounts-campaign-halt-icd-10

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