HMO hassles? Add them to the collection of complaints

Gathering "hassle factor" data helps medical societies pinpoint the most common problems physicians are encountering with managed care companies.

By Julie A. Jacob, amednews staff. Aug. 20, 2001.

Using the philosophy that knowledge is power, more and more state medical societies are keeping detailed databases tracking the hassles and frustrations their members encounter with managed care plans.

About two-thirds of state medical societies have "hassle log" programs in place, according to the AMA Private Sector Advocacy department. The programs give the medical societies concrete data on physician problems with the plans, which state societies can then use when meeting with representatives of managed care companies or state insurance departments.

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Although the programs vary from state to state, they usually work like this: Physicians fill out forms documenting the type of problem -- such as late claims payments, downcoded claims, excessive paperwork requirements -- and send them to their state medical society. The society then logs the information into a database that sorts and organizes the complaints by insurer, region and type of complaint.

The knowledge gleaned from tracking the number and types of physician complaints is helping state societies work more effectively to resolve issues, or at the very least to alert state insurance departments about problems, say state society staff members.

The Texas Medical Assn., for example, received about 5,000 complaint forms last year from physicians documenting their problems with denied or delayed payments, downcoded claims and administrative hassles, said Richard Johnson, the TMA's director of medical economics.

The TMA uses the information in its database as the basis for discussions at its regular meetings with representatives of managed care companies, said Johnson.

For example, he said, the TMA discovered that doctors were reporting a lot of problems with bundled and downcoded claims with Humana Inc.

"We were able to call this to their attention, although we have a long way to go to get it fixed," said Johnson.

The Illinois State Medical Assn. started a managed care hassle log last year as part of its new division of membership and advocacy, said Ronald L. Ruecker, MD, the state society's president and an internist in Decatur, Ill.

So far, the state society has received about 1,200 hassle log forms, which physicians can print out from the society's Web site or request through the mail.

"We weren't sure what to expect when we started the program, but we've had a very positive response," said Dr. Ruecker. The society has already identified two major issues of concern for state physicians, said Dr. Ruecker: bundling and automatic downcoding.

The Colorado Medical Assn. also uses its hassle log program as the basis for its bimonthly meetings with representatives of managed care companies, said Edie Register, the CMA's director of health care financing. The CMA receives more than 1,000 complaint forms per year, she noted.

The society asks doctors to submit documentation to accompany each complaint form, she said, so the society's staff members can pinpoint the problem and determine if it's the fault of the health plan or a problem with the physician's billing procedures.

The society compiles the results of its complaint program into quarterly reports, which are sent to both the managed care plans and the state insurance department. Instead of taking a confrontational approach with the health plans, said Register, the society simply presents them with the information and asks the plans to research the problem. If that isn't effective, the society can then ask the insurance department to investigate.

Doctors say the program is beneficial, she added, but "are frustrated that we can't help with every problem."

The Oklahoma State Medical Assn. also started a managed care hassle log in April, although it had informally tracked physician managed care complaints previously.

The society publicized its program through its journal and faxes sent to county medical societies, said Joy Leuthard, the society's director of health care policy and research.

So far, the medical society has logged more than 200 complaints from physicians. It is analyzing and sorting complaints going back to June 1999, and will present them to managed care company representatives at a meeting this month, said Leuthard.

Complaints received from physicians cover the spectrum of claims payment and administrative hassle issues, she said, and are spread out among the state's managed care plans.

The goal of the meeting will be to solve problems, Leuthard said. "The focus is to be positive, so we can look at developing positive solutions to the problems identified. ... We want it to be constructive."