Recap of 2000 A year in review before the rally for 2001

by Shellie Pruden, DCMS director of medical practice relations

It's been an amazing year in terms of socioeconomic issues. We've seen departures, reorganization, innovation, negotiation, standardization, and education.

The year began with the transition of Medicare HMO patients from four HMOs to the only two HMO products in the Dallas area.

Attorney General John Cornyn developed the controversial Agreement of Voluntary Compliance with Aetna US Healthcare. Medicine opposed portions of this agreement and asked for clarification regarding state law compliance, contracting issues, and all-products agreements. Meanwhile, Aetna changed national strategies, including reorganization of management, divesting a division, and dropping the US Healthcare from its name.

Amcare purchased Amerihealth. Magellan departed the public sector market in the Dallas service area. PacifiCare is recontracting its recently acquired Harris Healthplan business.

IPAs have seen changes, too. First, the reorganization of Southwest Physician Association, then Phycor exited the market, forcing physicians to rally to save SPA. Physicians, health plans, and the courts continue to negotiate and resolve the Genesis Physicians Practice Association bankruptcy. The rocky road doesn't end with these two IPAs. TMA and DCMS continue to receive complaints from physicians about nonpayment and slow payment by Heritage Southwest. The common thread of struggling IPAs seems to be management of risk contracts.

If that isn't enough to follow, the market also is experiencing technological advances. Physicians already are verifying benefits, processing referrals, and tracking claim payments via their computers. Soon they will be able to track and order prescriptions, get lab results, and file claims on the Internet.

Credentialing applications, referral forms, and clean claim definitions became standardized this year. The DFW Business Group on Health led the effort. On the heels of the successful Texas Common Credentialing Application, statewide stakeholders have developed a common referral form that will be tested and implemented in 2001. TDI concluded the rule-making process to implement House Bill 610, the clean claims legislation. As a statutory requirement, TDI worked with related agencies to develop the standardized list of required fields on a HCFA 1500 form that would facilitate claims adjudication under the time limits required by law.

With the increase in sophistication in the marketplace, demand for educational programs increased. DCMS Managed Care Committee offered two programs this year. The first, 10 Tips for Managing Managed Care, offered advice to physicians and their staff members on effectively filing and processing claims. The second annual Managed Care Expo on Oct 25 assisted physicians in dealing with negotiations, interaction with TDI, and HIPPA, and took a hard look at why claims are denied.

In preparing for the release of the Texas Health Care Information Council's Public Use Data File, DCMS assisted DFW Hospital Council with two educational seminars to educate hospital staffs and physicians on the potential impact of this release. The Dec 15 data release will include claims and outcome data from every hospital in Texas.

It's been a busy year. HIPPA, privacy, legislative agendas, and assistance with regulatory, managed care, and insurance issues are on the agenda for 2001. It's a fascinating time to advocate the business of medicine, and DCMS will continue to serve as a resource to member physicians.