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WCA Launches Per Diem Defense Plan

Thursday, November 5, 2015   (0 Comments)
Posted by: Sheri Ryan
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OPTUM ACTION PAGE

optum_HED

LINKS & DOWNLOADS WCA Template Letter [CLICK HERE] OCI Insurance Complaint 
Portal [CLICK HERE] OCI Complaint Form [CLICK HERE] 

INSTRUCTIONS

The WCA has filed a complaint with the Wisconsin Office of the Commissioner of Insurance (WI OCI) challenging the legality of the Optum per diem payment method. The WI OCI has opened an investigation into the Optum per diem payment method and is gathering information from Optum and Wisconsin Chiropractors on whether this method limits access to quality chiropractic care.
 The WCA is asking it members to submit supporting documentation to WI OCI showing that the
per diem payment method limits access to quality chiropractic care.
  • Select compelling patient cases (redacting any protected patient and proprietary financial information) where you can demonstrate that the Optum per diem payment method is limiting access to quality chiropractic care and submit it with the completed OCI complaint template letter.
HOW TO PROVIDE SUPPORTING DOCUMENTATION FOR YOUR OCI COMPLAINT
Select specific examples of patients losing access to and/or a decrease in the quality of care
provided,REDACTING ANY PATIENT IDENTIFYING INFORMATION.
  1. FOR EXAMPLE, DOES OPTUM OR UNITEDHEALTH GROUP’S PAYMENT OR COST CONTAINMENT MODELS RESTRICT YOUR ABILITY TO ADDRESS SPECIFIC PATIENT HEALTHCARE NEEDS AND INSTEAD FORCE YOU TO DELIVER MORE COOKIE-CUTTER SERVICES THAT MAKE NO SENSE FOR CERTAIN PATIENTS? IF SO, PROVIDE EXAMPLES, REDACTING ANY PATIENT IDENTIFYING INFORMATION.
  2. AS ANOTHER POTENTIAL EXAMPLE, HAVE YOU EXPERIENCED FREQUENT DENIALS OF DELIVERED SERVICES BY UNITEDHEALTH GROUP OR OPTUM AND A RECOUPMENT OF FUNDS PAID FOR THOSE SERVICES? IF SO, PROVIDE EXAMPLES AND THE FREQUENCY AT WHICH SUCH DENIALS/RECOUPMENT OCCURS. REMEMBER TO DELETE ANY PATIENT IDENTIFYING INFORMATION.]
  • Download the OCI compliant template letter, complete the blanks, and print on your company letterhead
  • Send these materials and this information to the Wisconsin Office of the Commissioner of Insurance.
  • Send a copy of your complaint to the WCA for our complaint records.
  • NOTE: when you contact OCI, please include “ATTENTION: WCA Complaint against Optum Health Solutions”

 

HOW TO REACH THE WISCONSIN OFFICE OF THE COMMISSIONER OF 
INSURANCE MAIL: 125 S. Webster Street, 
PO Box 7813, 53707 FAX: 608-264-8115 EMAIL: ocicomplaints@wisconsin.gov

 

IF YOU HAVE QUESTIONS CONTACT THE WCA

CALL 608-256-7023

EMAIL WCAHELP@WICHIRO.ORG

 


OPTUM_web_timelineWCA ACTION MEMO

FROM: WCA Executive Director John Murray
TO: WCA Members
RE: Optum Per Diem Payment Plan

 

Since WCA members were first informed of the Optum per diem payment method being imposed in Wisconsin earlier this year, the WCA has been aggressively challenging this action alleging it violates state and federal non-discrimination laws ensuring equal access to quality chiropractic care.

“WCA has been at the forefront of challenging the Optum per diem payment model since it was announced,” said WCA Executive Director John Murray. “We are committed to challenging this action using every feasible option at our disposal.”

The Wisconsin Commissioner of Insurance has opened an investigation into the legality of the Optum per diem payment method at the request of the Wisconsin Chiropractic Association. The WCA filed a complaint with OCI on behalf of its members on September 14, 2015 and OCI received this complaint and opened the investigation into Optum on September 18, 2015 according to OCI spokesman J.P. Wieske.

As a follow up to the complaint, WCA was able to secure a meeting with OCI Deputy Commissioner Dan Schwartzer and OCI General Counsel Jim Boll on October 13, 2015 to discuss the status of the WCA/Optum complaint and gain further clarity as to OCI’s interpretation of the insurance equality statute. Attending the meeting on behalf of WCA was Executive Director John Murray, WCA legal counsel Barbara Zabawa and WCA lobbyist Tom Moore.

“We appreciated the opportunity to meet with top OCI officials and gain a better understanding of how they see their authority to enforce the insurance equality law,” said John Murray WCA Executive Director.

In a follow up letter to Deputy OCI Commissioner Schwartzer, the WCA reiterated what was discussed in the October 13 meeting and specifically outlined the areas where OCI would have the ability to intervene in a provider contract.

The letter reads in part:
“Specifically, OCI views Wisconsin’s Insurance Equality Statute at 632.87(3) as a consumer protection statute that addresses provisions in agreements between consumers and health insurers only. We understand OCI’s position to be that if a consumer’s insurance policy creates barriers to seeing a chiropractor as compared to seeing a physician, OCI would intervene to ensure that the insurer complies with Wis. Stat. § 632.87(3). However, if a provision in a contract between a provider and insurer results in unequal treatment of a chiropractor compared to a physician, OCI will not intervene or opine on those alleged discriminatory contractual provisions, unless those contractual provisions do one of two things:
1. Create a barrier to chiropractic access for the consumer as compared to physicians; or
2. Violate a provision of insurance law that explicitly governs the relationship between an insurer
and provider (such as Wis. Stat. §§ 609.22 or 609.30).

“Now that we have a clear understanding of the narrow situations in which OCI will intervene in provider contracts, we can craft a more specific case to show that Optum is violating the law,” said WCA Executive Director John Murray.

The WCA is urging chiropractors in Wisconsin to send supporting documentation to bolster the complaint focusing on situations where the Optum per diem payment policy is limiting access to care or compromising quality of care.

“WCA has done everything it can to develop the strongest case possible against the Optum per diem payment method,” said Murray.  “We are asking our members to help provide the case specific information that will bolster our case that the law is being violated and access to chiropractic care is being affected.”

[CLICK HERE] to read WCA Executive Director John Murray's October 23 letter 
to the OCI Deputy Commissioner Dan Schwartzer

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