A membership survey by the Medical Society of the State of New York shows physicians tend to see health plans as interfering in good patient care. Of 1,200 doctors surveyed, 88% said they believe that insurers generally have a negative impact on doctors' ability to treat patients, 90% said they had changed treatments based on carriers' restrictions, and 92% said financial incentives or disincentives offered by the plans "may not be in the best of interest of patients." But most of the doctors also said they go along with the rules for fear of being eliminated from a network. Only 14% said they were not at all concerned about being removed from a plan's list of providers. MSSNY President Michael Rosenberg said the group commissioned the survey after getting complaints from members. The response rate to the e-mail survey was about 10%.
The Coalition of Behavioral Health Agencies is lobbying New York's congressional delegation to block the new Upper Payment rule, which would cut Medicaid funding for the state's providers. The coalition argues that many clinics would be forced to close or reduce services. Methadone programs in the state, for example, could be reduced by as much as $100 million as a result of the rule, leaving as many as 20,000 patients without services. The state estimates that the rule would reduce federal support by more than $350 million. HANYS, the coalition and other groups are trying to halt implementation of the new Medicaid outpatient department and clinic regulation, which would redefine the formula used to determine the maximum amount that Medicaid can pay for OPD and clinic services. The federal Office of Management and Budget is reviewing the proposed rule.
Insurers recover the amount they pay for bariatric surgery 53 months after the operation because patients have fewer or cheaper claims than they otherwise would have, according to research in the current American Journal of Managed Care. For laparoscopic procedures, the estimated return on investment is only 25 months, according to the research. The authors used claims data for more than 3,600 patients who underwent a bariatric procedure and for a matched control group to estimate the break-even time from an insurer's perspective. The study says that the mean bariatric surgery investment ranged from $17,000 to $26,000. It is available at http://ajmc.com/Article.cfm?Menu=1&ID=10708
New York barely audited home health agencies for Medicaid fraud before this year because auditors saw the industry as a jobs program for the state. That's the reason that James Sheehan heard for the oversight when he became Medicaid Inspector General last year.
In 2007, the federal government mandated that the state pursue Medicaid fraud more aggressively. Using data-mining techniques, Mr. Sheehan is making New York far more sophisticated about spotting abuses in the home care industry, he told an audience of home health agency managers at a compliance seminar organized by the Home Care Association of New York State last week. "We want to make sure you understand the audit process and what the rules are," he said.
The inspector's goal is to emulate the credit card industry, where front-end
controls keep the loss ratio at 0.07%. That means catching fraud before it
happens. New York spends $45 billion annually on Medicaid.
"We make a lot of
payments that, after the fact, it turns out we should have done something
differently," Mr. Sheehan said.
Auditors once determined which of New York's 100,000 home care agencies to audit by how much the state paid them and the date of their last audit. New tools let auditors zero in on agencies with high error rates or other problem indicators.
