This page contains a Flash digital edition of a book.
LEGISLATIVE AFFAIRS


Broken silence TMA wins “silent PPO” legislation


BY AMY LYNN SORREL Plano psychiatrist Philip Koren- man, MD, thought he had a clean slate after cancel- ing most of his health in- surance contracts by 2008. The last one ended in De- cember 2012. He informed his patients, too, so they understood he no longer accepted the insurance plans or the payment rates he once negotiated with them in exchange for a steady volume of patients. So when years later,


some of his patients came in with explanation-of-ben- efit forms indicating that Dr. Korenman was still in network for some of those plans and that his patients were eligible for reduced rates on his services, he knew those “discounts” were somehow taken im- properly. Finding out exactly how that happened mired Dr. Korenman and his staff in a web of detective work to trace the discounts back to their sources. In one case, months of phone calls, fax- es, and digging through old paperwork revealed that a 1993 contract rate he can- celed in 2003 was applied


third-party administrators, which access those con- tracts to manage claims on behalf of payers such as employers and health plans.


Confused? So was


Philip Korenman, MD, holds just one of several volumes of insurance contracts he had to dig through to determine how his contract rates were getting shared among different networks and companies. New TMA-won legislation helps eliminate that detective work so that physi- cians know up front who and what they are dealing with in network contracting.


to a patient’s claim nearly 20 years later in 2012. As it turned out, the contract — even though it was obsolete — was bought and sold among several preferred provider organizations (PPOs), which assemble and rent out physician networks, and


Dr. Korenman. He didn’t even recognize the name of some of the compa- nies because he never directly contracted with them. Some of them had consolidated; others he tried to call were out of business. Yet, behind the scenes, mysterious entities used his old contract rates without his permission and seemingly without any rules. That left Dr. Koren- man with no recourse but to take the task on himself before seeking help from the Texas Medical Associa- tion’s Payment Advocacy Department. “It’s a very nerve-racking situation,” he said. “I am trying to run a practice and take care of patients, while doing all this sleuth work. And I’m worrying in the back of my mind, is this going to turn into a legal issue, and are these insurance companies going to come after me and ac-


cuse me of breaking my contract?” More importantly, “patients are the ones who get hurt,” Dr.


Korenman added. They are led to believe physicians are in network when they are not; they wonder why they are not


September 2013 TEXAS MEDICINE 41


JIM LINCOLN


Page 1  |  Page 2  |  Page 3  |  Page 4  |  Page 5  |  Page 6  |  Page 7  |  Page 8  |  Page 9  |  Page 10  |  Page 11  |  Page 12  |  Page 13  |  Page 14  |  Page 15  |  Page 16  |  Page 17  |  Page 18  |  Page 19  |  Page 20  |  Page 21  |  Page 22  |  Page 23  |  Page 24  |  Page 25  |  Page 26  |  Page 27  |  Page 28  |  Page 29  |  Page 30  |  Page 31  |  Page 32  |  Page 33  |  Page 34  |  Page 35  |  Page 36  |  Page 37  |  Page 38  |  Page 39  |  Page 40  |  Page 41  |  Page 42  |  Page 43  |  Page 44  |  Page 45  |  Page 46  |  Page 47  |  Page 48  |  Page 49  |  Page 50  |  Page 51  |  Page 52  |  Page 53  |  Page 54  |  Page 55  |  Page 56  |  Page 57  |  Page 58  |  Page 59  |  Page 60  |  Page 61  |  Page 62  |  Page 63  |  Page 64  |  Page 65  |  Page 66  |  Page 67  |  Page 68