Avoiding PPO Sales Slip-Ups

Welcome to Part II of our survey. 10 PPOs in California diligently answered direct questions about their plans. Our readers, who are savvy health brokers, suggested many of the questions. We hope this information will help the professional agent or broker better serve sophisticated healthcare clients. We offer a special thanks to the insurance carriers that took the time to answer our lengthy questionnaire. We interpret their careful responses as a sure sign of their high level of commitment to the professional agent.

Forewarned is Forearmed With Our Annual PPO Survey

8. Which Requested Procedures are Denied Most Frequently on the Basis of "Experimental/Investigative” or “Not Medically Necessary” Exclusions?

Aetna: We seek to minimize the number of claims denied based on medical necessity through our extensive patient management program, which includes features such as pre-certification, concurrent review, and close communication between our staff and attending physicians.
Blue Cross: It varies greatly. Each request is reviewed on a case-by-case basis to determine medical necessity based on the latest medical standards.
Blue Shield: Each request is reviewed on an individual basis to determine medical necessity. We do not have statistics on which procedures are denied most frequently.
Cigna: CIGNA has a comprehensive policy for ensuring the efficacy of the latest medical treatments. We have an extensive process that includes review of outside, professional literature and input from physicians to determine the safety and efficacy of procedures and interventions. We work closely with members and physicians to help determine treatment protocols that ensure appropriate and quality care, while reducing the number of denials.
Guardian: This information is unavailable at this time.
Health Net: N/A.
Kaiser Permanente: Requests are received on a case-by-case basis.
Nippon Life: We do not track denied claims in this manner.
UnitedHealthcare: UnitedHealthcare does not deny procedures on the basis of medical necessity and our benefit plans do not contain medical necessity exclusions. We believe that healthcare consumers and their doctors are best qualified to make decisions about healthcare. Denials on the basis of "experimental or investigative” are very rare. If an individual has a life-threatening sickness or condition (one that is likely to cause death within one year of the request for treatment), we may determine that an experimental, investigational, or unproven service meets the definition of a covered health service for the sickness or condition. This determination is based on whether we find the procedure or treatment to be promising and that we find that the service uses research protocol that meets standards equivalent to those defined by the National Institutes of Health.

9. Do you Capitate PPO Providers? If Not, How are they compensated?

Aetna: No, physicians are paid based on a negotiated fee schedule, which compensates physicians at the lesser of their usual charge or the negotiated fee. Each of our networks has a unique fee structure. We incorporate the federal government’s RBRVS methodology for procedure-related services while allowing for local differences for office and hospital visit services.
Blue Cross: No, payment is determined by applying available member benefits to a pre-determined fee schedule.
Blue Shield: No, PPO contracted providers (physicians including ancillary providers) have agreed to accept Blue Shield’s allowances as payment in full, which are valued-based and reviewed annually.
Health Net: PPO physicians are typically reimbursed at a discounted contract-fee schedule.
Cigna: No, we reimburse physicians on a maximum allowable fee schedule or a discounted fee-for-service arrangement.
Guardian: We do not capitate PPO providers. Compensation is based on fee-for-service.
Kaiser Permanente: No, our PPO providers are part of the Private Healthcare Systems (PHCS) Network. The PHCS Network contracts with the providers to negotiate a lower rate for services rendered. Providers are paid based on claims submitted for covered services.
Nippon Life: No, providers are paid on a fee-for-service basis.
UnitedHealthcare: Yes, however, the majority of physicians in our networks are reimbursed according to a Maximum Allowable Fee Schedule based on the Resource Based Relative Value Scale Fee Schedule (RBRVS). Our fee schedule is established by applying a conversion factor to RBRVS values. The conversion factor is based on competitive market conditions, medical expense expectations, and physician acceptance. The advantage of this funding arrangement is that we reimburse physicians only for services rendered based on time and intensity with adjustments for geographical differences. For some high-cost specialists, we employ prepayment (capitation). This ensures that we are able to manage expenses for high-cost services to a planned target.

10. What Happens When a Member Provider Bills a Participant Inappropriately for Services?

Aetna: Balance billing of the patient is not permitted. The provider relations staff monitors compliance and educates providers. A provider who is found to have inappropriate balance billing may have their contract terminated in some cases.
Blue Cross: Customer service works with the member and provider to resolve billing issues. Dispute-resolution procedures are available to members and providers.
Blue Shield: Network providers are prohibited from balance billing patients. When a participant is billed inappropriately for services, Blue Shield customer service representatives can usually resolve it by contacting the provider’s office to clarify the member’s benefit and the Blue Shield reimbursement schedule.
Cigna: Our contracts prohibit balance billing by physicians. The member should contact the health plan about the issue. The plan will investigate.
Guardian: The member is not responsible for the charges. The network is notified so that they can educate the provider.
Health Net: Health Net will intervene on the member’s behalf by working directly with the provider’s office.
Kaiser Permanente: If a provider bills a member inappropriately, the member should contact the KPIC customer service line. If the issue requires any type of special handling, KPIC operations staff will intervene and help in reconciling the claim.
Nippon Life: If a participating provider bills an insured for services inappropriately, we will give our insured the information necessary to have the problem resolved. If necessary, we will communicate directly with the physician.
UnitedHealthcare: Our physician and other healthcare professional contracts preclude physicians and other healthcare professionals from balance billing enrollees. Appropriate action may include the following:
• Change to or reduction in payment.
• Financial offsets, modifications to reimbursement or other terms of the physician contract.
• Ineligibility to participate in designation or recognition programs other measures as identified in connection with a specific protocol.
• Termination of the physician contract. Physicians and other healthcare professionals may view a complete list of UnitedHealthcare protocols online at www.UnitedHealthcareOnline.com

We protect our customers from claims liability by fulfilling all state mandates concerning participation in guaranty associations, maintaining state contingency reserve requirements, or obtaining reinsurance agreements. Our standard hospital contracts also contain provisions to protect people receiving health services from balance billing when an insurer becomes insolvent. We help reassign people enrolled in our plans to other physicians. If a network physician or other healthcare professional becomes insolvent or otherwise unable to continue to render healthcare services to people.

11. Do You Have a Registered Nurse on Call 24 Hours a Day for Questions at the Plan Level and the PPO Level?

Aetna: Yes, nurses provide information on a broad spectrum of health issues virtually 24 hours a day, seven days a week. They also provide ongoing follow-up information as needed and perform customized research when appropriate. Standard service is included in the full-risk, prospectively rated PPO plan. The informed Health Line may be purchased as an additional service for self-funded or retrospectively rated PPO plans with 1,000 or more total enrolled employees. The minimum group size can be a mix of active employees and retirees (for example, 800 active and 200 retirees).
Blue Cross: Yes, most PPO members have access to professional, reliable healthcare information toll-free, 24 hours a day, seven days a week. Registered nurses answer questions and help with decisions. Members also have access to educational audiotapes on more than 200 health topics.
Blue Shield: Yes, Blue Shield’s NurseHelp 24/7 is a service for all of our fully insured groups in California and is available as a buy-up for self-insured groups. It provides a nurse-line, which is staffed 24 hours a day, seven days a week with registered nurses and master’s-level counselors. Any member of a fully insured Blue Shield health plan in California can take advantage of this service at no extra charge.
Cigna: Yes.
Guardian: Yes, this is provided through our Nurseline program, which is through Optum.
Health Net: Yes, Health Coaches provided through Decision Power include nurses, respiratory therapists, pharmacists, and dietitians with an average of 15 years of experience in their field. They are available 24 hours a day, seven days a week to answer questions and address any members’ concerns. A health coach gives support and guidance when a member is facing important health decisions and will provide the most recent evidence-based information. All Health Net’s members get Decision Power as part of their benefit offering. The health coaches are easily accessible through a toll-free telephone number or at www.healthnet.com.
Kaiser Permanente: Members have access to Kaiser Permanente Healthy Solutions, which provides personal health coach, online health and wellness programs and information, and the Kaiser Permanente Healthwise Handbook online.
Nippon Life: A registered nurse is on call 12 hours a day for questions. A conversant message system is available after hours.
UnitedHealthcare: Yes, Optum, the UnitedHealth Group care management company, provides toll-free, 24-hour, 365-day access to NurseLine. Experienced registered nurses discuss treatment options and help people get the appropriate level of care. NurseLine gives people information that helps them make educated decisions about their personal health and use of medical resources. Some services must be purchased as a buy-up based on the funding arrangement of the plan.

12. What is the Plan or PPO Doing to Have Online Systems for Eligibility, Administrative Changes, Referrals, Etc.?

Aetna: EZLink streamlines several benefits and HR functions. It links to our enrollment and billing systems and provides real-time eligibility; online enrollment, account maintenance, on-line billing, and electronic-funds transfer for payment.
Blue Cross: Our Website offers online services to providers and members for eligibility, claim status, and benefit inquiries. Other features include a provider finder and a wide variety of Web and organizational resources.
Blue Shield: Yes, Blue Shield’s NurseHelp 24/7 is a service for all of our fully insured groups in California and available as a buy-up for self-insured groups. It provides a nurse line, which is staffed 24 hours a day, seven days a week with registered nurses and master’s-level counselors. Any member of a fully insured Blue Shield health plan in California can take advantage of this service at no extra charge.
Cigna: The CIGNA for Health Care Professionals website (www.healthnet.com) offers secure and easy access to real-time transactions, such as precertification, claim status, eligibility, and benefits. Information on CIGNA policies and procedures is also available. In addition, CIGNA has enhanced the myCIGNA.com portal, which enables members to personalize their site. They can review hospital and provider quality data, gather specific disease information, track claims, and explore cost-saving drug alternatives.
Guardian: Guardian has an online Web tool available for plan members, benefit administrators, providers, and brokers that is available 24 hours a day to help in benefits look-ups, administration, and eligibility. Guardian also has an online provider search tool available 24 hours a day, which allows members to do the following:
• Customize their search by specialty, languages spoken, gender and more.
• Get side-by-side comparisons of provider information (for example, office status, distance)
• Create a short-list of favorite providers.
• Search for a healthcare provider based on a medical condition.
• Get maps and directions to a provider’s office.
• View their results online or have them faxed or emailed to them.
• Save their search criteria for easy access when revisiting the Provider Online Search.
• Create a customized provider directory.
• Nominate a provider to be included in a network.
Health Net: Health Net’s secure website, www.healthnet.com, requires a personalized identification number (PIN). Members, employers, providers, and brokers can perform a wide range of online administrative functions. Members in an active or COBRA program can view or modify their enrollment information. Providers can verify eligibility, find specialists for referrals, and submit and check claims status. Health Net eServices for members, brokers, and employers offers 24-hour online account access to process enrollment and maintain members’ eligibility; and view, print and pay billing. Enhancements for both sites are ongoing.
Kaiser Permanente: Kaiser Permanente offers online billing and administration functions to its employer groups through a system called “Online Account Services.”
Nippon Life: All of our information about eligibility, administrative changes, etc. is available on our mainframe computer. Services for eligibility and administrative changes are available online. Referrals are handled by phone.
UnitedHealthcare: Each member, physician, and employer has access to their data and the capability to communicate directly with us online. Our consumer Internet solution (myuhc.com) allows members to do the following:
• Choose a plan.
• Locate network professionals.
• Access claims history and explanations of benefits.
• Complete a health assessment and develop an action plan.
• Order ID cards and print temporary ones.
• Communicate with a nurse.
• Compare hospitals.
Healthcare professionals can do the following:
• Verify patient eligibility, applicable co-payment amounts, and year-to-date and out-of-pocket accumulators.
• Search the notification database and complete multiple notifications in one session.
• Submit claims.
• Get payment statements and reimbursement.
• Perform online reconciliation and electronic funds transfer.
• Submit credentialing data online.
• Complete online continuing education (CE) programs. The following features are available through employer management solution, Employer eServices:
• Get Web-based eligibility management
• Get simplified invoices, real-time calculations and downloadable data
• Do customer reporting

13. What is the Relationship of your HMO Provider Network (if you have one) to Your PPO Provider Network? Do HMO Providers Have to Participate in the PPO Network? How big is your PPO Network compared to your HMO Network?

Aetna: Standard provider contract provisions generally apply to all of our plans and products that the provider participates in. However, it is not mandatory for a provider to participate in all products.
Blue Cross: All of our California networks are proprietary, whether they are PPO/HMO/EPO etc. A provider may participate in one or more of our plan products, but it is not mandatory for a provider to participate in all products. Our PPO network has 46,449 physicians and our HMO network has 31,434 physicians.
Blue Shield: No, not all HMO providers have to participate in our PPO network, though many of them do. According to our most recent totals, Blue Shield of California’s PPO network has more than 63,548 physicians (defined by access points) and 355 hospitals and our HMO network has more than 32,600 physicians (defined by access points) and more than 300 hospitals. Blue Shield of California’s HMO and PPO networks are separate. The HMO network is capitated based on medical group and IPA contracts throughout the state with some directly contracted networks in specific geographies. With the PPO, there are valued-based allowances and contracts with individual physicians and medical groups.
Cigna: Cigna does not require PPO network physicians to participate in the HMO (or vice versa). The HMO network is contracted with CIGNA HealthCare of California, Inc. Whereas the PPO network is contracted with Connecticut General Life Insurance Company, a CIGNA company. While there is considerable overlap, we have many physicians just in one network (e.g. PPO only). In California, our HMO network is 80% of the size of our PPO Network
Guardian: Guardian does not offer HMO Medical
insurance.
Health Net: Health Net of California has taken a multi-product approach in contracting with providers, with 65% of Health Net’s PPO network practitioners also participating in the HMO network. While HMO providers do not have to participate in Health Net’s PPO network, 88% of them do so. Health Net of California’s HMO network includes 41,000 practitioners in the 30-county HMO service area, and the PPO network includes 56,000 practitioners statewide.
Kaiser Permanente: Our PPO and HMO networks are not affiliated. For our PPO, KPIC contracts with PHCS Network to provide access to providers and facilities nationwide. They currently have more than 450,000 providers and 4,200 acute care facilities nationally and more 65,000 providers in California. Our HMO offers more than 8,000 providers and 160 facilities in California.
Nippon Life: We do not have an HMO network of
providers.
UnitedHealthcare: While we have allowed physicians to participate in one product and not another in the past, our current contracting and re-contracting strategy has been to implement “All-Payer/All Product” contracts in all of our networks. The All-Payer contract language allows any UnitedHealthcare authorized payer health plan, self-funded customer, or specialty company to access the contract terms and rates. The All Product contract language obligates physicians and providers to participate in all applicable UnitedHealthcare plans. UnitedHealthcare’s provider network in California includes 50,000 physicians and 322 hospitals.