[House Hearing, 110 Congress]
[From the U.S. Government Publishing Office]
SUBCOMMITTEE HEARING ON ENSURING
PROMPT PAYMENT FOR SMALL HEALTH
CARE PROVIDERS
=======================================================================
SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE
COMMITTEE ON SMALL BUSINESS
UNITED STATES HOUSE OF REPRESENTATIVES
ONE HUNDRED TENTH CONGRESS
FIRST SESSION
__________
AUGUST 1, 2007
__________
Serial Number 110-39
__________
Printed for the use of the Committee on Small Business
Available via the World Wide Web: http://www.access.gpo.gov/congress/
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HOUSE COMMITTEE ON SMALL BUSINESS
NYDIA M. VELAZQUEZ, New York, Chairwoman
HEATH SHULER, North Carolina STEVE CHABOT, Ohio, Ranking Member
CHARLIE GONZALEZ, Texas ROSCOE BARTLETT, Maryland
RICK LARSEN, Washington SAM GRAVES, Missouri
RAUL GRIJALVA, Arizona TODD AKIN, Missouri
MICHAEL MICHAUD, Maine BILL SHUSTER, Pennsylvania
MELISSA BEAN, Illinois MARILYN MUSGRAVE, Colorado
HENRY CUELLAR, Texas STEVE KING, Iowa
DAN LIPINSKI, Illinois JEFF FORTENBERRY, Nebraska
GWEN MOORE, Wisconsin LYNN WESTMORELAND, Georgia
JASON ALTMIRE, Pennsylvania LOUIE GOHMERT, Texas
BRUCE BRALEY, Iowa DEAN HELLER, Nevada
YVETTE CLARKE, New York DAVID DAVIS, Tennessee
BRAD ELLSWORTH, Indiana MARY FALLIN, Oklahoma
HANK JOHNSON, Georgia VERN BUCHANAN, Florida
JOE SESTAK, Pennsylvania JIM JORDAN, Ohio
Michael Day, Majority Staff Director
Adam Minehardt, Deputy Staff Director
Tim Slattery, Chief Counsel
Kevin Fitzpatrick, Minority Staff Director
SUBCOMMITTEE ON REGULATIONS, HEALTH CARE & TRADE
CHARLES GONZALEZ, Texas, Chairman
RICK LARSEN, Washington LYNN WESTMORELAND, Georgia,
DAN LIPINSKI, Illinois Ranking
MELISSA BEAN, Illinois BILL SHUSTER, Pennsylvania
GWEN MOORE, Wisconsin STEVE KING, Iowa
JASON ALTMIRE, Pennsylvania MARILYN MUSGRAVE, Colorado
JOE SESTAK, Pennsylvania MARY FALLIN, Oklahoma
VERN BUCHANAN, Florida
JIM JORDAN, Ohio
.........................................................
______
.........................................................
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Gonzalez, Hon. Charles........................................... 1
Westmoreland, Hon. Lynn.......................................... 3
WITNESSES
Wilson, Dr. Cecil B., American Medical Association............... 4
Merrill, Dr. Robert, D.D.S., American Association of
Orthodontists.................................................. 5
Henkes, Dr. David, Pathology Associates of San Antonio........... 8
Austin, Dr. Gordon T., D.M.D., Northwest District of the Georgia
Dental Association............................................. 10
Kelly, Dr. Frank B., American Academy of Orthopaedic Surgeons.... 11
APPENDIX
Prepared Statements:
Gonzalez, Hon. Charles........................................... 21
Westmoreland, Hon. Lynn.......................................... 23
Wilson, Dr. Cecil B., American Medical Association............... 24
Merrill, Dr. Robert, D.D.S., American Association of
Orthodontists.................................................. 32
Henkes, Dr. David, Pathology Associates of San Antonio........... 36
Attachments to Dr. Henkes Testimony.............................. 48
Austin, Dr. Gordon T., D.M.D., Northwest District of the Georgia
Dental Association............................................. 65
Kelly, Dr. Frank B., American Academy of Orthopaedic Surgeons.... 67
(iii)
SUBCOMMITTEE HEARING ON ENSURING
PROMPT PAYMENT FOR SMALL HEALTH
CARE PROVIDERS
----------
Wednesday, August 1, 2007
U.S. House of Representatives,
Committee on Small Business,
Subcommittee on Regulations, Health Care & Trade
Washington, DC.
The subcommittee met, pursuant to call, at 10:00 a.m., in
Room 2360 Rayburn House Office Building, Hon. Charles Gonzalez
[Chairman of the Subcommittee] presiding.
Present: Representatives Gonzalez, Larsen, Altmire, Shuler,
and Westmoreland.
OPENING STATEMENT OF CHAIRMAN GONZALEZ
Chairman Gonzalez. The Subcommittee on Regulation, Health
Care and Trade on Small Business will come to order. Today's
hearing is on ensuring prompt payment for small health care
providers.
I am going to begin with an opening statement, but I do
want to preface my remarks as well as the remarks by the
ranking member, thanking each and every one of the witnesses.
Please understand this is probably the busiest time of the
session for Members of Congress because we are supposed to go
on the August recess and we are trying to do a few things
before we leave either Saturday or Sunday or it could be Monday
or Tuesday. We are not sure. But we are hoping certain Members
will come through.
Also understand you have submitted written testimony and
that testimony is actually reference material for us. And the
questions that we will be posing today will again inform us,
enlighten us and guide us. And staff is here, of course, and we
count on them to take a lot of notes but we do that ourselves.
Again, thank you very much. And I am hoping we will have
members--as a matter of fact, we have been joined by
Congressman Shuler at this time. Members may come in and out,
and that is just the nature of the beast around here because
there are so many demands being made on Members. And the Chair
will recognize himself for an opening statement.
Small physician groups face many challenges today.
Unfortunately, many of these have nothing to do with practicing
medicine. Whether it be the increase in bureaucracy of managed
care or the prospect of reduced Medicare reimbursements, it can
be extremely difficult to make these businesses profitable.
Today's hearing will look at one of the biggest financial
challenges facing the industry. Payments from insurance
companies to health care providers have long been a concern of
health care providers and their member organizations. Providers
have shown that some insurers delay payments for a significant
portion of the insurance claims. This often leads to cash-flow
problems and increases the cost of care for the patients that
they serve.
Such conditions are particularly problematic for small
health care providers. As small businesses, they just cannot
afford to be exposed to the sort of instability that an
unpredictable revenue stream creates. Payment delays are
nothing more than an unfair business practice that let
insurance companies earn interest on money owed. Cash flow is
an important issue for the small practice and late payments
hinder their ability to run and expand their businesses.
The insurance community argues that the prompt payment of
claims is not a problem, that the market in concert with State
laws will address any lingering problems. This subcommittee is
interested in our witnesses' responses to that particular
assertion. Small providers lack the financial resources to hold
insurance companies accountable for their failure to make
timely claim payments. If an insurer is unwilling to make a
payment or wants to delay payment, what remedy do small
practices have at hand to compel payment unless we provide them
with one? Only prompt payment laws that are enforced make it
possible for small providers to be paid in a timely and fair
manner.
Efforts to enact prompt State payment laws have been
successful. To date, all 50 States and the District of Columbia
have prompt payment rules that apply to insurers. These laws
were designed to help small providers who lack the ability to
negotiate payment schedules with insurers or to compel payment.
As such, small business health providers can rely on State
efforts as opposed to hiring their own attorneys to enforce
these requirements.
But there is a problem. States do not seem to be
effectively cracking down on insurers who are not complying
with State prompt pay laws. In part, the focus of today's
hearing is to understand why prompt pay laws fail to be as
successful as providers once hoped. Ultimately, health care
providers need prompt payment laws that are meaningful in
practice, not just on paper. I believe this means promoting
stricter enforcement of existing laws, strengthening prompt
payment requirements and holding more health plans accountable.
Though prompt payment laws can be found throughout the
country, providers seem to uniformly agree that they are far
from effective. This is a significant source of frustration for
State insurance commissioners who have directed considerable
resources to enforcing compliance and providers who are
challenged by the problem daily. Without a solution, small
practices will continue to struggle.
I would like to thank again each witness. We look forward
to your testimony. And at this time I am going to go and yield
and recognize the ranking member, Congressman Westmoreland, for
an opening statement.
OPENING STATEMENT OF MR. WESTMORELAND
Mr. Westmoreland. Thank you, Mr. Chairman , for holding
this hearing today. This is a very important hearing,
especially for the medical profession. I would also like to
thank all the witnesses for your participation. And I am sure
that today's testimony will prove to be very helpful to this
committee and to our Congress.
Payment for service is the core of our economic system. No
industry would survive if those who bought a product only paid
a fraction of what it cost. But that is exactly what is
happening to physicians in our health care industry. And not
only are physicians often paid less than what their services
cost, they are also being paid well after the bill comes due.
So not only do you not get all your money, you don't get it in
a timely fashion. The ironically named prompt payment issue is
one that is affecting physicians and patients all over the
country. Surveys have shown that it is at the forefront of
physicians' concerns and I know that from listening to many
physicians that come into our office every day to complain
about the system. And their payment schedule is one of the
things that they complain the most about.
I don't know about any of you, but when I visit my doctor,
I want his full attention to be on what he is doing and not
wondering if he is going to get paid for seeing me. Almost
every State has enacted some form of prompt payment law in an
effort to address this very real issue. Unfortunately, these
laws usually have very little enforcement and therefore allow
the problem to persist.
I am proud that my home State of Georgia has one of the
most comprehensive laws governing payment for medical services.
Our law requires that insurers pay claims within 15 working
days of receipt. While this law has helped, it has by no means
eliminated the insurance companies' desire to withhold payment.
This Congress faces a great challenge as it tries to lower
the overall cost of health care, while also providing access to
those who need it. I hope that we can all agree that
shortchanging our physicians is counterintuitive to having an
effective health care system. I know that today's hearings will
be helpful in addressing this challenge.
And again I want to thank the Chairman for having the
hearing. And I welcome this distinguished panel, and thank all
of you for your willingness to testify today. Thank you.
Chairman Gonzalez. Thank you very much. Is there anyone
else who wishes to make an opening statement? I want to welcome
Dr. Rob Merrill. It says on our agenda that he is representing
the orthodontists which are based in St. Louis, Missouri. But I
want the record to be very clear that Rob is a citizen-resident
of the great State of Washington with Nancy Washington. I have
known him and his family for a long time, 10 to 15 years I
guess it must be by now. So I really appreciate the hearing,
but I wanted to especially welcome Dr. Merrill to the hearing.
Thank you very much. We will proceed with the testimony. I
would advise the witnesses that you have 5 minutes, and I know
that may not be sufficient time, but we will try to hold you to
the 5 minutes. But also understand we will have follow-up
questions. And since we don't have as many members present, we
are going to have a little bit more time and you will be able
to again probably supplement some of the comments you wish you
had covered during your testimony.
The first witness will be the testimony of Dr. Cecil B.
Wilson. He is the immediate past chair for the Board of
Trustees for the American Medical Association and has been on
the Board of Delegates since 1992. The AMA is the largest
medical association in the United States. Dr. Wilson has been
in private practice of internal medicine in central Florida for
30 years. Dr. Wilson.
STATEMENT OF DR. CECIL B. WILSON, M.D., BOARD CERTIFIED
INTERNIST, IMMEDIATE PAST CHAIR, BOARD OF TRUSTEES, AMERICAN
MEDICAL ASSOCIATION
Dr. Wilson. Thank you, Chairman Gonzalez, Ranking Member
Westmoreland, and members of the subcommittee for the
opportunity to testify today. My name is Cecil Wilson. I am the
immediate past Chair of the Board of Trustees for the American
Medical Association. I am also an internist from Winter Park,
Florida.
The focus of today's hearing is of great importance to the
medical community given that 52 percent of physician practices
in this country have three or less physicians and account for
80 percent of outpatient visits. Small physician practices have
limited leverage relative to large insurance companies since
antitrust laws prevent physicians as a group from addressing
payment and other contract terms on a level playing field. The
ability of physicians to address unfair payment practices
continues to diminish with the increasing consolidation of
health insurers.
In the majority of metropolitan statistical areas, a single
health insurer dominates the market. The growing disparity in
negotiating positions has created an environment where insurers
are able to evade prompt payment laws with little, if any,
adverse consequence. This has a financially debilitating effect
on small physician practices and could limit patient access.
When one side has all the market power, more efficient market
mechanisms are hampered.
A common problem confronted by many physicians is insurers
paying claims late. Even if a claim includes all the
appropriate information, insurance companies often find reasons
to delay or deny payment. This is tantamount to small physician
practices extending interest free loans to large insurance
companies.
In addition, this seemingly intentional behavior by the
insurer creates an onerous administrative burden. Physicians
and their staff must spend hours on the phone pursuing payment
of unpaid claims. In fact, growing numbers of physician
practices have been forced to hire office staff dedicated
solely to collecting late payments. Because of this, some have
had to eliminate services and clinical staff positions as well
as forego equipment upgrades and the adoption of health
information technology.
Fundamental fairness warrants timely payment. As the Chair
has stated, in 50 States and the District of Columbia,
legislation and regulations have been passed tied to the prompt
payment of claims. Despite this, physicians still experience
problems with receiving payments from health plans in a timely
manner. Evidence of the continuing problem is that State
regulators have imposed more than $76 million, including fines,
interest, restitution and statutory penalty fees against third-
party payors for late payments to physicians and other health
care providers.
And it is not just State regulators who have understood the
problem. In 2000, a number of individual and class action
lawsuits were consolidated and eventually certified to cover
more than 600,000 physicians. The suits were brought to address
violations of prompt pay laws as well as other payment
violations by some of the Nation's largest for-profit health
plans. Settlements were reached with most of the insurers.
However, these short-term solutions will begin to sunset
this year. The AMA urges Congress to pass legislation that will
establish a strong Federal prompt pay standard, protect more
robust prompt pay State laws by ensuring the Federal standard
is the floor, establish concurrent jurisdiction over
enforcement between the State and Federal Government, clarify
that State prompt payment laws apply to all ERISA-covered
health plans, strengthen penalties to prevent plans from
considering fines and other associated financial sanctions as
merely the cost of doing business, protect physicians from
retaliation by insurers if they pursue their remedies under the
prompt pay laws and expand protections to address other tactics
utilized by health insurers to delay or decrease payments.
The AMA looks forward to working with the committee to
achieve our shared goals of strengthening and safeguarding the
viability of small physician practices and providing quality
care to patients.
Thank you for the opportunity to be here today.
[The prepared statement of Dr. Wilson may be found in the
Appendix on page 24.]
Chairman Gonzalez. Dr. Wilson, thank you very much for your
testimony. The next witness is Dr. Rob Merrill. Dr. Merrill is
Chairman of the American Association Orthodontist Committee on
Governmental Affairs. He is a board certified orthodontist and
has been in practice since 1990. The AAO comprises 15,000
members in the United States, Canada and abroad.
Dr. Merrill.
STATEMENT OF DR. ROBERT MERRILL, D.D.S., M.S., BOARD CERTIFIED
ORTHODONTIST, CHAIRMAN, COMMITTEE ON GOVERNMENT AFFAIRS,
AMERICAN ASSOCIATION OF ORTHODONTISTS, ST. LOUIS, MISSOURI
Dr. Merrill. Chairman Gonzalez, Ranking Member
Westmoreland, and distinguished members of the subcommittee, on
behalf of the American Association of Orthodontists, I thank
you for your leadership in holding this important hearing to
address issues related to late payment and benefits by
insurers. As the current Chairman of the Association's Counsel
on Government Affairs, it is my honor to have the opportunity
to share the experiences and perspectives of its member
orthodontists as the committee considers ways to alleviate the
problems caused by the late payment of benefits.
Orthodontists are uniquely qualified and educated dental
specialists who correct improperly aligned teeth and jaws.
There are currently 9,200 actively practicing U.S. members of
the AAO. Orthodontics is one of America's finest examples of a
thriving small business community. The Nation's orthodontists,
over 75 percent of whom are solo practitioners that employ an
average of seven dental service professionals, currently
provide care to an estimated 4.4 million adolescents and 1
million adults. Just over 60 percent of patients nationwide
have insurance coverage that includes an orthodontic benefit to
one degree or another. In my own office, approximately 55
percent of our patients have orthodontic insurance benefits.
The best insurance companies pay claims within 30 days, not
unlike the best patients who are also prompt in paying their
bills, so we don't have to send out multiple statements
requesting payment.
The average orthodontic practice is often hard hit by
economic downturns as families often defer what may be
perceived as elective orthodontic treatment. Often underscoring
these financial difficulties is the practice of insurance
companies that delay payments to orthodontic practices and thus
cause additional hardship for the practice and its patients.
As health care providers, orthodontists care about the
quality of treatment of their patients and have a personal
interest in the success of treatment. Since there are a
relatively small number of orthodontists nationwide, we believe
it is likely that insurance companies view the practices as
lightweights that can be moved to the back of the line when it
comes to payment of benefits. In short, this issue is about
fairness as it involves large powerful insurance companies and
their relationship to small community based health care
providers and their patients.
I would like to describe five ways in which late payment of
benefits by insurers specifically harms the average orthodontic
practice, a system used by one insurer that works well in my
practice and outlines several areas where legislation could
potentially help.
One, cash flow problems. As small businesses, it is
important to keep a steady and consistent cash flow in order to
pay salaries of employers, the employees, vendors, and to
upgrade equipment in order to provide the best, most
technologically advanced care to patients. Late payments by
insurers complicate cash flow, thus causing numerous accounting
problems that require additional time, resources and staff to
alleviate.
Two, increased burden on patients. Many orthodontists in
recent years have stopped processing insurance claims since the
cost of hiring additional administrative staff to comply with
insurance company red tape outweighs the benefit they receive
in return. Regrettably, this causes additional strain for the
patient, who is then burdened with the task of completing
complicated reimbursement forms and communicating with the
insurance companies.
Three, administrative costs. Higher costs of insurance
company compliance results in overall costs of patient care
being increased. Many of the Nation's orthodontists who have
longstanding practices report that insurance company benefits
for orthodontic treatment have remained unchanged for over 20
years. This means even patients who are covered by insurance
often bear the entire burden of increased health care costs.
Four, non-duplication of benefits. A related issue that
affects orthodontists is what is termed non-duplication of
benefits. This means that patients are covered by more than one
insurance policy, yet the second policy will refuse to make any
payment on behalf of the patient. It may be that both parents
or a parent and a step-parent are employed and have paid the
premiums for insurance that includes orthodontic coverage, yet
will be unable to receive the benefit because of a non-
duplication clause in the insurance policy. This means that the
employee who happens to have insurance coverage through a
spouse cannot access their benefits equally to an employee
working for the same company who is not covered by the
insurance plan even though both are paying the same premium.
This situation is unfair to those who are paying for a benefit
and not receiving it. This needs to be remedied. Therefore, the
AAL believes that consumers who pay for insurance coverage
should get the full extent of the coverage they are paying for
instead of getting caught in a tangled maze of paperwork that
ends with a denial of payment by the second insurer. Congress
should require that where families have multiple dental benefit
plans, each plan will pay a portion of the dental care claim
according to their contracted scope of benefits, not to exceed
100 percent of the amount of the claim.
Five, coordination of benefits. The treatment fee is such
that both plans will usually end up paying their maximum, but
the secondary insurer will refuse payment until a primary
estimate of benefits is received, causing additional payment
delays and increased paperwork and expense for the office and
insurance company alike. An effective repayment system that
works best for my office from an insurance company are the ones
that pay automatically once the initial billing is received.
This cuts down on expense and increased work hours for both the
orthodontic office and the insurance company. Manual monthly
insurance billing is very time consuming and adds to the
administrative expense for both the practice and the insurance
company and this ultimately costs the patients more.
The AAL appreciates the opportunity to share the
experiences and perspectives of our member orthodontists as the
committee considers ways to alleviate the problems caused by
late payments of benefits. I hope that the testimony I have
offered has been valuable for that end, and I hope that if the
AAL can be of further assistance to this committee, you will
not hesitate to call upon us.
[The prepared statement of Dr. Merrill may be found in the
Appendix on page 32.]
Chairman Gonzalez. The next witness is from San Antonio,
and he is Dr. David Henkes. I have known David--I know, Rick,
you were saying you had known Dr. Merrill for a number of
years. I hate to even tell you how long I have known David. He
was starting his residency and I was already a seasoned 5-year
lawyer, which is way, way back. And we share many things in
common and that is a great passion for the University of Texas
Longhorns.
Dr. Henkes hails from San Antonio. He is a board certified
pathologist and the immediate past President of the Bexar
County Medical Society in San Antonio. He currently sits on the
Board of Trustees for the San Antonio Medical Foundation and is
on staff with Christus Santa Rosa Health Care, one of the top
health care organizations in all of south Texas. Dr. Henkes is
also a partner and practicing pathologist with Pathology
Associates of San Antonio.
Dr. Henkes.
STATEMENT OF DR. DAVID HENKES, M.D., BOARD CERTIFIED
PATHOLOGIST, PATHOLOGY ASSOCIATES OF SAN ANTONIO, PAST
PRESIDENT, BEXAR COUNTY MEDICAL SOCIETY, SAN ANTONIO, TEXAS
Dr. Henkes. Congressman Gonzalez and Ranking Member
Westmoreland, and other members, I want to thank you very much.
I would be nervous in giving this testimony except that I look
at your friendly face.
Overall in Texas the prompt pay laws we have passed have
been helpful, but they haven't really gone far enough. There
are still some bad actors out there. In December of 1995,
UnitedHealthcare was fined $4 million for violations. There is
also the problem where the insurance companies tend to say they
are ERISA and so therefore these are not regulated by States.
Since most of their claims are ERISA, that has been an issue.
As you mentioned practicing in Christus Santa Rosa, it is a
very--I am very honored and very happy to do that, but it is a
very high Medicaid and Medicare and indigent population. So you
can imagine how slow pay and no pay has a real impact on our
practice, especially when we have specialized pediatric cardiac
surgery, pediatric oncology, and we have to attract talent for
their special pathology needs.
I want to tell you about an example in our practice that we
had that extends beyond just the typical, you know, the slow
pay for a claim submitted. In 2004, UnitedHealthcare had sent
out a notice saying they would no longer pay for clinical
pathology services. Clinical pathology services are services
that pathologists provide to hospital laboratories for
oversight and direction and usually comprise 25 to 35 percent
of the time that a hospital pathologist spends doing those type
of services. They said they were going to follow the Medicare
model and to pay the hospital, which is indeed what Medicare
does. But that is not the model of private insurance companies
in Texas, and every other one pays us on a separate component
basis. They said the services were covered and we should look
to the hospital for that reimbursement. We did and the hospital
said we are not being paid. They gave us signed statements of
that and we asked them if they had any increase for the
nonpayment to pay through to us and they said no. We went back
to United and they said, oh, well, okay, we will change that,
what we are going to do is--they changed their position and
said we are going to go ahead and pay you a little bit more for
your anatomic services to cover for these clinical services.
Well, that brings in an ethical consideration because a number
of patients who don't have clinical services--they don't--they
have anatomic services and may not have clinical services. So
they are paying for those other patients. And so we challenge
that. And then finally, after having this within the Department
of Insurance for Texas for almost 2 years, we got a letter back
from them just giving us a letter from United saying that they
no longer recognize this service. And so we are not sure
exactly what that means, whether it is covered or uncovered or
what we need to do with that.
In essence, what I recommend is that this committee not
only look at the existing rules and regulations from the States
that are out there, but look at more detail at some of the
other practices like what I have just mentioned and help us in
terms of addressing those particular practices. I would suggest
some of the following recommendations.
One, that insurance companies must state whether disputed
services are covered or not covered, recognized or
unrecognized. If a service is covered, it should be paid; there
should be a payment for that service. Insurance companies
should not be allowed to increase payment for one service to
cover no payment or lesser payment for another unless it is
specifically agreed to by both parties in a written contract.
Payment to someone other than the provider or person who is
authorized by that provider for reassignment should be
prohibited.
The committee should consider a single set of rules on
claims processing by all insurance companies as clinically
based so there is transparency in the claims processing system.
In cases of dispute requiring arbitration, the insurance
company should pay the majority of the arbitration costs and
contracts should not have provisions to deter class action
arbitration or litigation. And just on that last particular
item, we are currently in a class action arbitration and they
are throwing up a number of hurdles about that basically so
that it has made it very difficult but it will go forward and
it should go forward.
I would be happy to answer any other questions. I
appreciate your time and consideration.
[The prepared statement of Dr. Henkes may be found in the
Appendix on page 36.]
Chairman Gonzalez. Thank you very much, Doctor. At this
time the Chair is going to recognize the ranking member,
Congressman Westmoreland, for the introduction of the next two
witnesses.
Mr. Westmoreland. Thank you, Mr. Chairman . I want to
recognize Dr. Gordon Austin, a third generation dentist who
graduated top of his class at the Medical College of Georgia.
He completed his oral and maxillofacial surgery residency at
the Naval Hospital in San Diego in 1993 and is board certified
by the American Board of Oral and Maxillofacial Surgery and the
National Dental Board, certified by anesthesiology.
Dr. Austin served for 11 years on active duty in the U.S.
Navy and continues to serve in the reserves with 30 years of
continuous service. Captain Austin was mobilized to the
National Naval Medical Center in Bethesda, Maryland for
Operation Desert Storm in 1991 and again in 2003 for Operation
Iraqi Freedom.
Dr. Austin has been in private practice since 1987. He
lives in Carrollton, Georgia, with his wife Meredith and
daughter Courtney. And Lindsay lives up here in Washington, his
other daughter. But Captain Austin served from 2002 until 2005
as the Reserve Officers Association National Dental Surgeon. He
is currently the President of Northwest District of Georgia
Dental Association. He is a friend of mine and a constituent.
And welcome, Dr. Austin.
STATEMENT OF DR. GORDON T. AUSTIN, D.M.D., P.C., BOARD
CERTIFIED ORAL AND MAXILLOFACIAL SURGEON, PRESIDENT, NORTHWEST
DISTRICT OF THE GEORGIA DENTAL ASSOCIATION, CARROLLTON, GEORGIA
Dr. Austin. Thank you, Chairman Gonzalez. With the last
name Austin, I certainly have a close kinship to the great
State of Texas. Ranking Member Westmoreland, thank you for
those comments, and members of the committee. I deeply
appreciate this opportunity to testify before you on the issue
of ensuring prompt payment for small health care providers.
This is an issue of national interest and significant
importance.
There are currently at least 48 different State prompt pay
laws, with to my calculation only South Carolina and Idaho not
having such laws. In the complex environment of health care,
any opportunity to decrease this complexity should be acted
upon.
Again, my name is Gordon Austin, DMD. I practice oral and
maxillofacial surgery in rural Georgia. And as an oral and
maxillofacial surgeon, I practice in both the hospital and the
office setting. As a surgical specialty, oral surgery bridges
the gap between medicine and dentistry. I file both medical and
dental insurance claims. I am a Medicare provider and I am a
Medicaid provider.
I have submitted written testimony and other information,
so I will keep my remarks brief to allow as much time as
possible for questions.
Although I am a proud member of the Georgia Dental
Association, I come before you today not representing any
organization but as a small businessman with a business issue.
There are a couple of points I would like to emphasize.
As a congressional committee with expertise on small
business, it is certainly no surprise to you that as a small
business it is vital that I be paid promptly for my services.
Secondly, I believe action on this issue is a reasonable
responsibility of the Federal Government because of the
interstate commerce issues involved. Although I practice in
Georgia, I file claims with insurance companies across the
United States. A reasonable time frame for payment should be a
consistent and national standard. ERISA plans are exempt from
prompt payment laws, so Federal legislation would be necessary
to fully establish the national standard.
Thirdly, will it work? Is it doable? Currently under
Georgia Dental Medicaid with the ACS and Avesis insurance
companies, I can examine a patient on Tuesday, do their surgery
on Thursday, and have the money directly deposited in my
account on Monday. If some of the Georgia Medicaid insurance
companies can do this, any third party payor can if they are so
motivated. Yet I have submitted to you documentation of a
recent far too common case of services which I provided in
March that still has not been paid in August, along with a lot
of the phone calls and documentation provided to the company.
This demonstrates the unreasonable time and unnecessary expense
to my office spent resolving many claims.
Again, I thank you for this opportunity. I look forward to
answering your questions.
[The prepared statement of Dr. Austin may be found in the
Appendix on page 65.]
Mr. Westmoreland. Thank you, Dr. Austin. Now it is my
pleasure to introduce Dr. Frank Kelly, who serves as Chair of
the Communications Cabinet of the American Academy of
Orthopedic Surgeons. Dr. Kelly also practices at the Forsyth
Street Orthopedic Surgery and Rehabilitation Center in Macon,
Georgia. A notable member of Georgia's medical community, Dr.
Kelly has practiced in Macon for over 25 years. And he is a Phi
Beta Kappa graduate of the University of North Carolina at
Chapel Hill before completing his medical training at the
Medical College of Georgia and his orthopedic residency at the
University of Tennessee Campbell Clinic.
Dr. Kelly is the past President of the Georgia Orthopedic
Society and is currently serving as a member of the Board of
Directors of the American Academy of Orthopedic Surgeons,
representing over 24,000 orthopedic specialists worldwide.
I want to thank Dr. Kelly for his willingness to come share
his thoughts, and I look forward to hearing his testimony. Dr.
Kelly, welcome.
STATEMENT OF DR. FRANK B. KELLY, M.D., BOARD CERTIFIED
ORTHOPAEDIC SURGEON, CHAIR, COMMUNICATIONS CABINET, AMERICAN
ACADEMY OF ORTHOPAEDIC SURGEONS, MACON, GEORGIA
Dr. Kelly. Thank you very much, Lynn. When I get back home,
I don't know whether to tell my friends I went fifth or last.
But perhaps fifth sounds better. Good morning once again,
Chairman Gonzalez. And good morning again, Ranking Member
Westmoreland. And good morning to other distinguished members
of this subcommittee.
As Lynn mentioned, my name is Frank Kelly. I am a
practicing orthopedic surgeon in my hometown of Macon, Georgia.
I also have the pleasure of serving as a member of the Board of
Directors of the American Association of Orthopedic Surgeons.
And I served as a Chair of our organization's Communications
Cabinet.
On behalf of my organization and behalf of my colleagues
across the country, I sincerely thank you for asking me to
testify this morning on this very significant issue of prompt
payment for health care services.
As a practicing physician and as administrator of a seven-
person practice, I am deeply concerned that the Federal
Government has simply not done enough to ensure that physicians
in practices like mine are paid promptly by insurers. Having
now been in practice for almost 30 years, I have witnessed
firsthand how this delay in reimbursement has not only made it
more difficult for us to run our practices, but it has already
had the very real potential of adversely affecting the quality
of care we deliver to our patients.
Though we have tried to cooperate with insurance companies,
unfortunately the vast majority of so-called clean claims,
those claims submitted in accordance with the insurer's own
guidelines, are not reimbursed in a timely manner. In fact, as
has been mentioned several times this morning, these claims can
average 3 to 6 months before payment and they can constitute a
very major burden for those of us who depend upon this income
for the day-to-day operation of our practices.
In response to concerns from physicians nationwide in an
attempt also to address this significant problem, as has been
mentioned already, almost all States have enacted prompt
payment laws mandating that third-party payors reimburse claims
in a reasonable time period. My home State of Georgia, as has
been mentioned this morning, is fortunate to have one of the
most comprehensive and effective laws governing prompt payment
for medical services. Under our State law, insurers must
process payment within 15 working days after receiving these
clean claims, otherwise pay a penalty of up to 18 percent of
the benefit due.
Our insurance commissioner, John Oxendine, has been
unyielding in his enforcement of this law and in his commitment
to our State's physicians, ensuring that big insurance
companies don't take advantage of our small medical practices.
Unfortunately, Commissioner Oxendine's reach extends only so
far under the current Federal law. Approximately half of my
patients and over 100 million patients across our country are
covered by self-funded insurance plans which fall under ERISA,
the Federal Employee Retirement Income Security Act. And
according to the Supreme Court's decision in a 2004 case, these
ERISA plans are exempt from State prompt payment regulations.
As a result, thousands upon thousands of claims are slipping
through the cracks in this system.
While insurance companies may argue that the administrative
burden of processing claims prohibits timely payment, I find
this to be a hollow and very ineffective argument. Even
Medicare, the Nation's largest health plan, adheres to a higher
standard than do these ERISA plans. In fact, the Social
Security Act requires that accurate Medicare claims be
processed in 30 days or be subject to a significant interest
penalty. Prior to the enactment of our State's prompt pay law,
practices like mine relied heavily on Medicare for our monthly
cash flow to meet the expenses of running our practices. Many
of my colleagues and States with less aggressive prompt pay
statutes still struggle with late payments from private
insurance companies. They still depend upon Medicare
reimbursements to cover their expenses.
Though much work still needs to be done, I have seen the
very positive impact of Georgia's prompt payment regulations on
our State's health care system and on the many hard working
physicians and small businesses within it. I am confident this
problem of delayed reimbursements can be overcome throughout
our country. This will require accommodation of at least three
things.
Number one, effective, extensive prompt payment
legislation.
Secondly, the accurate determination of what really
constitutes a clean claim.
And thirdly, and perhaps most importantly, appropriate
enforcement mechanisms to ensure that insurance companies are
adhering to these regulations.
Our association supports prompt payment within a 30-day
timeframe. Such timely reimbursement will allow us to spend
more time doing what we were trained to do, and that is taking
care of our patients.
On behalf of my orthopedic colleagues, on behalf our
association, I thank you very much for your time and for your
interest and for the opportunity to express to you my concerns
about this most important matter. Thank you very much.
[The prepared statement of Dr. Kelly may be found in the
Appendix on page 67.]
Chairman Gonzalez. Thank you, Dr. Kelly. We have been
advised we have got two procedural votes and I think we have
the 10-minute bell. Around the 5-minute bell we will head out
back to the floor, vote. Two procedural votes, that could mean
anything. Congressman Westmoreland could probably give me some
insight as to what the Republicans have in store for us. I
don't think he will. As soon as we are through, we will come
back. I will ask one question and get it started. Then we will
probably have to excuse ourselves. Please stick around. Staff
will tell you more or less the time frame once we get down
there and start voting. But there are two votes and conceivably
that could be 20 minutes or 30 minutes.
But Dr. Wilson, there are certain things that kind of
resonate. First of all, it appears everybody is in agreement
that there is a role for the Federal Government and yet still
leave room for State mechanisms to take effect, which I think
is always the best thing we can do. But one thing that struck
me in reading the testimony from all of you, but especially Dr.
Wilson and I believe Dr. Kelly and some others, this thing
about uniformity. It is surprising to me that at this point in
time that there isn't some sort of uniformity on what a clean
claim looks like, the minimum amount of information that has to
be reflected on there that would be sufficient, though, for the
insurer to go ahead and act on it, because it appears that
there is a game that goes on obviously. And I think I will get
to Dr. Henkes and he can explain what happened in his
particular episode in San Antonio.
But have there--obviously there have been efforts to try to
come together on what some sort of uniform information would be
required?
Dr. Wilson. Yes. Thank you, Mr. Chair. And certainly there
have been and certainly the AMA has been involved in a lot of
those efforts, in getting uniformity in terms of the claim form
as well as the requirements for a clean claim. The challenge,
of course, is that each of the insurance companies is an
independent business. They sometimes would claim that there is
some antitrust provisions that would prevent them from
cooperating in some ways. I don't think we buy that argument.
But the reality is they have not been able to come up with
something they all agree with that would mean a clean claim.
The other thing that physicians face is what is called
black box edits, and that is for any one insurance company they
won't tell the physician what their requirements are. So you
might have 10 companies you deal with and at a minimum if they
would just let you know, what are the 10 things that ought to
go into a clean claim, that would help the physician.
Frequently those are considered proprietary and not available
and not provided. So the physician finds out what is missing
from a claim when he gets the claim back and says, well, you
missed this. And unfortunately, sometimes you will correct that
and then you get the claim back again and say by the way, here
is something else we want you to correct as well. And each of
those, of course, retolls the hours in terms of prompt pay
which make that a challenge.
The point is well made. We need some uniformity there. And
there are times when the Federal Government can provide that
uniformity and this is one of those.
Chairman Gonzalez. Sir, we always hear here in Congress
that many times whatever Medicare--what the United States
Government through Medicare establishes, what would be a
reimbursement rate for any procedure, a protocol and so on that
generally insurers will then adopt that particular baseline
reimbursement rate. Is that accurate?
Dr. Wilson. The reality is more and more of the insurance
companies are pegging their rates. They won't necessarily make
that the same rate. But if as is anticipated--and we would hope
Congress is going to block that. If we come January 1 and are
faced with a 10 percent cut in Medicare payments, you can be
sure that insurance companies will look at that and adjust
their rates. Now, they won't all come down to Medicare levels,
but they will use that as a model which then will obviously
impact everyone adversely.
Chairman Gonzalez. The reason I ask that, it seems that
they are pretty willing to go ahead and adopt that which the
Federal Government may establish if it works to their advantage
but not necessarily other practices by the Federal Government
when it comes to, say, Medicare. So I think we can maybe give
them a little bit of guidance.
At this time, the committee will stand in recess and we
will reconvene as soon as that second vote or the last vote.
Thank you for your patience and see you in a few minutes.
[Recess.]
Chairman Gonzalez. The subcommittee will reconvene at this
time. I will yield to the ranking member for any questions he
might have since I had the privilege of getting a few minutes
in earlier.
Mr. Westmoreland. Thank you, Mr. Chairman . And I want to
thank all of you for coming. And I know a lot of people don't
look at it as being--in the medical profession as being a small
businessman. But coming from a small business background and
knowing some of you personally, I know that it is a small
business and that cash flow is critically important. And I am
going to ask Dr. Austin this. Does a delay in provider
reimbursement threaten to Dr. ve some of the small providers
out of business? And if that happened because of this pay
issue, what would the effect be on both the provider and the
patients?
Dr. Austin. Thanks for the question. I just wanted to say
to the Chairman I really appreciated his comment about the
Medicare rules. I believe you get it, that the insurance
companies use what is to their advantage and this card was not
to their advantage.
It is really pretty simple in terms of running a business.
The more hassles you have in a business, the more difficult it
is to make a profit, the lower incentive there is to go into
the business. So if the bottom-line continues to deteriorate,
it is harder and harder to attract the best and the brightest
to the professions. It is particularly problematic for small
specialties like my own.
The orthodontist as previously--the issue of being an
orthodontist. When I was on the Medicare Carrier Advisory
Committee, I was talking to the medical director about some
issues that we had. And he said, you know, Gordon, we get 6,000
complaints from the cardiologists and we get six complaints
from the oral surgeons and we just don't have time to get to
your issues. And so that is really what happens to the small
practitioners, is that we get pushed to the back of the line.
And because we are small, it affects us more. If I do four
surgeries in a day and one of those claims doesn't get paid,
that is 25 percent of my income that doesn't happen. If you
were in a large group, that is a smaller percentage and more
easily absorbed. So it affects the smallest businesses, the
smallest practitioners the most.
Mr. Westmoreland. Just one follow-up if I could. And this
would be to anybody because you may all have different
circumstances. But what are some of the excuses or practices or
dilatory things that these insurance companies do to prevent
you from being paid promptly.
Dr. Austin. It is pretty easy in my case. I do the same
type of procedures over and over and over again and we face the
same issues. A large part of my practice would be taking out
wisdom teeth on a young person. We know that they are going to
ask for an X-ray. We know that if we take out a little cyst,
they will ask for a path report. And we know if they are a
student, they will ask for proof of student status. We
routinely send these in with the claim and yet we routinely get
the claim back saying send us an X-ray. We call them and say
you have the X-ray. They say, oh, yes, we do have the X-ray.
They say send us the student status. We sent you a student
status. Oh, well, maybe we didn't get it. So they know what
stops the clock, and that is really what the issue is. The
States have put a clock on them to pay the claim and they know
if they can say it is not a clean claim, they are missing
something, it stops the clock. So even when we send it, stamp
on the claim that we sent it, they still when we call them or
get the letter back, they ask for something we have already
sent them.
Dr. Kelly. If I might, I would like to echo Gordon's
comments because I found the same situation in my orthopedic
practice. One of the things I do, as you might imagine very
commonly, is a knee injection. It is a very simple technique.
It takes just a few moments. The same situation. We will submit
the claim, they will send a letter back that always says--they
send it back and they say we notified your patient 17 days ago.
They always say 17 days ago that we received this bill and we
need to have from you the patient's history and physical, any
pertinent lab tests, pertinent X-rays, progress notes, anything
to game the system.
I think the Chair had it right earlier. I think it is
almost like a game they are playing just to delay payment. So
we have the same situation with knee injections in our
procedures that Gordon does in his practice and it has just
escalated.
Dr. Merrill. Probably the most common thing with braces is
when there is two insurance policies that cover--the average
fee for braces is well in excess of what the lifetime maximum
is. And secondary insurers will delay payment by saying, well,
we are not going to issue our estimate of what we are going to
pay until after the payment is received from the first insurer
so we know what they'll pay and then we'll tell you what we are
going to pay, even though both are going to pay that full
amount. It is just a matter of being able to delay it an
additional 3 to 4 months, which provides uncertainty to the
patient. The patient is, like, do I have this or do I not, am I
going to have to find another $1,000 or $1,500 to pay towards
this or will my insurance pay for it? And my office staff have
to explain that to the patients and they don't understand how
the insurance companies work. And so it is very disconcerting
to the patients when that happens, as well as being a problem
for cash flow as you have alluded to.
Dr. Wilson. One of the things that has happened along with
the prompt pay laws in States is insurance companies now have a
new category, which is called pending review. And so you get
the report back--and I mentioned this in my written testimony--
that pending review doesn't tell you what it is they are
looking at. It is like a concurrent audit and then that
postpones the prompt payment and then ultimately they will say
what it is that they want.
Mr. Westmoreland. And just a little follow-up to that. Like
Dr. Gordon and Dr. Austin and I am sure Dr. Merrill, you do the
same thing over and over. So you know what they are going to
ask for. Is there any type of checklist or something that you
send in with a claim or is there requirements that they have
given you that you routinely know? I mean, I understand how
they are doing it, but I mean, it is really inexcusable if you
do these things over and over and over and know what they are
going to ask. Would one patient be different from another?
Dr. Kelly. I will start that, Lynn. I think the incredible
thing about this is we use the insurer's own guidelines. They
ask us what to submit. We use their own guidelines for our
claims. And even though we have followed their guidelines to
the letter, they still come back requesting other information.
I would request that sometime when you are in the Macon
area, please stop by my office for 30 or 45 minutes. You will
be just absolutely amazed at the type of requests that we get
from the insurance companies.
So they have guidelines, we go by them. It doesn't seem to
matter.
Dr. Austin. The claim itself--we have codes and the codes
very clearly define as to what the procedure is that we are
doing. So in theory, when we have submitted that claim with the
code, we have told them exactly what we are doing, how we are
doing it. And as I said, with Medicaid I can send it in on
Thursday and have the money in the bank on Monday. It is not a
matter that they can't do it. It is purely a matter of in their
minds it is a business advantage to not pay in a timely manner.
And they are much better at it than I am.
And that is kind of where the issue comes in. The best
people that are gaming the system are the insurance companies.
The next people are the people that do regulations, Medicare,
that set guidelines. But the person that is least able to
really keep up with the changes is the small practitioner. So
we are always a little behind the curve. The insurance company
is always a little bit ahead of the curve and the regulations
are somewhere in the middle.
Dr. Henkes. Congressmen, as well, you have to realize too
if you have four or five major players in one area, you are
also playing with four or five different sets of rules. And
that is why I believe that the more uniformity in the sets of
rules would be better. Each one may have their own sets of
rules, as Dr. Wilson had mentioned. Some of these are black box
edits. They won't even tell you what the rules are.
Dr. Wilson. I guess the other observation about, well, can
they do it if they want to--well, someone said how does it
happen with Medicare. And clearly there are rules for Medicare.
And while if you look at prompt payment for Medicare across the
board, it is about somewhere in the middle. However, for
example, in my own personal example, which is solo medicine--
and I file electronically and I can tell you that the Medicare
carrier meets the requirements, the 14-day requirement for a
turnaround on electronic billing. And it seems to me that--and
obviously those are the major health insurers who are
contracted with Medicare. And that to me speaks to the issue
that if the incentives are appropriate, if the cloud is there,
in this case the Federal Government, then they will be able to
meet some standards that are put in place.
Chairman Gonzalez. The Chair is going to go and recognize
Jason Altmire. And again, Congressman Altmire, thank you for
joining us.
Mr. Altmire. Thank you, Mr. Chairman and Mr. Ranking
Member. I would just say very briefly it looks like we will
have some disruption here to this hearing but that should not
indicate that this committee doesn't understand the
significance of health care as an issue to small businesses.
And I just wanted to thank each and every one of you while we
had you here together for your appearance here today and let
you know we want to continue working with you as we move
forward on this issue. There is no issue like this across the
business world where small businesses are affected by health
care every single day, every business in the country. And I
really appreciate the fact, we appreciate the fact that you
took the time out of your day to come help us with this hearing
and walk us through your issues. And we look forward to
continuing that discussion and just to apologize again for the
disruptions that apparently we are going to be facing
throughout the hearing. Thanks.
Chairman Gonzalez. Thank you very much. Let me direct a
question to Dr. Henkes. You pointed out an interesting case
that you had with UnitedHealth and it is not for us to paint
with a real broad brush. But nevertheless, the concern that we
have, Republicans, Democrats, it doesn't matter, is that we
have a business model that has been institutionalized by the
insurance industry. The insurance industry is a very essential
component to the way we do business in this country and we need
a healthy insurance industry. But nevertheless, our fear now is
that they have basically built into their business model a
manner in which to delay payment for what very well could be
obviously the business considerations of holding on to that
money, the investments and so on that it brings. So, Dr.
Henkes, you have pointed out the experience with UnitedHealth
and how you had to go and address that obviously.
The other thing that you pointed out in your written
testimony was the concern--and some of the other witnesses also
pointed out and I wanted to touch on this quickly--and that is
some Federal clarification legislatively on the application of
ERISA and how that plays a part in maybe complicating what can
be done with insurers and the question of prompt payment. What
is the position on ERISA and how do you see it?
Dr. Henkes. Well, I don't think that the picture is
entirely clear. From my understanding on this, there has been
some discussions with the Department of Trade and that they
have seen some ambiguity into whether this really has any kind
of--they have jurisdiction over the prompt pay on this. We know
at the Texas Department of Insurance there has been ambiguity
by the researchers there as to whether the current laws apply,
being State laws on to--for ERISA plans. I actually am on an
advisory committee for an insurance company in Texas and they
have taken the position that they do not. Of course I don't
think this one has been actually totally played out. I think
there may have been one court case in another State that may
have given some credibility that maybe payment issues are not
necessarily preempted by ERISA. But there still is a lot of
ambiguity.
So I guess at this point, I think the State agencies, as
well as the Federal, are in ambiguity in how this affects on
the ERISA plans. And I think that is why it is so critical to
have you and this committee look at that to give that clarity
and give that clarity that if it requires passing another law
or if the compliance--that this is a part of State law.
Chairman Gonzalez. I will advise you all--and I would need
to do more research on this. I didn't have time to do it and
check the status. H.R. 979 is the Bipartisan Consensus Managed
Care Improvement Act of 2007, and it would amend ERISA. Among
some of the provisions would be to impose prompt payment
requirements on all employer-sponsored health plans. The act
requires such plans to pay all clean claims consistent with
existing requirements under the Medicare program.
So obviously there are other committees that share
jurisdiction. Much to our credit, the chairwoman of this
committee, Chairwoman Velazquez, was able to expand the
jurisdiction of this committee to share some of the
jurisdiction with other committees. So we still have to work in
unison. So it is obviously being addressed. We just need to see
where we can try to coordinate this.
Dr. Kelly, I think you were pointing out again, if we can
come up with the proper role for the Federal Government and, of
course, Dr. Wilson was also very specific as to what extent we
could do that. Dr. Austin also touched on that and I think that
is going to be our focus. What can we do to come in with a
Federal standard? Again, that is establishing basically the
floor, working with the States, which would be really more of
the enforcement mechanism, and of course if they have higher
standards, not to interfere and meddle with that. At least that
is my perspective, and I think Congressman Westmoreland may
have a different take on it.
Also, I think we need to start looking at uniformity out
there so that we don't have companies that basically say we
don't have the information, you add on to it. If they choose to
do that, there should be an additional burden placed on them
with some consequences. And that is the only way you ever get
accountability, is where there is consequences, which I don't
think we have that at the present time.
So there is much to be worked on. By the same token, I also
wish to address many of the other items that you may have
brought up in your written testimony addressing other trouble
spots, not just the prompt payment. But I think that right now
for the purpose of this hearing--and we will share the other
recommendations and observations you made as to other, what I
would say, difficult areas in practicing medicine.
I also want to make another observation, and that is simply
that this is the Small Business Committee. Most physician
practices are small businesses, as has been pointed out. We
recognize that you all are in a very unique position as
physicians. You have to conduct yourselves as a business so you
can open your doors in the morning and make sure that they are
open every day. And that is a business. Nevertheless, I still
consider you the last standing profession in the United States
of America, and somehow you have to maintain that even in a
business environment, and we are here to help you do that.
We have another vote. We are going to be leaving in a few
minutes, and I don't know how long it is going to take. So what
we are going to be doing is basically adjourning and letting
you all catch your flights and such. And I know some of you
said you wanted to take some pictures. So I want to give them
that opportunity.
So at this time, I would yield to the ranking member for
any comments he may have or any follow-up questions.
Mr. Westmoreland. Thank you, Mr. Chairman .
Mr. Westmoreland. Let me just thank you for having this
hearing because I think this is a very important issue. I do
agree the Federal Government does need to have a part in it.
One quick question. How many private insurers handle
Medicare in your States, do you know a number?
Dr. Wilson. For Florida, it is just one.
Mr. Westmoreland. For Florida it is only 1.
Mr. Wilson. It is Blue Cross/Blue Shield.
Dr. Henkes. In Texas we have the standard program, a
Medicare program, but there are some replacement programs, HMO
replacement programs.
Mr. Westmoreland. Medicare Advantage type thing?
Dr. Henkes. There are probably 5 or 6 of those, maybe 6 or
7.
Mr. Westmoreland. In Florida it says there are 289
different plans for the Medicare Advantage; is that true?
Dr. Wilson. The answer is I do not know that, and I
responded to the wrong question. When you said Medicare, I tend
to think of the Medicare carrier and not the Medicare Advantage
plans, but there are a lot of them.
Mr. Westmoreland. Okay.
Dr. Henkes. We can get that information for Texas.
Mr. Westmoreland. I was wondering, I know the Medicare
Advantage is a little bit different program than Medicare
itself, with a little different payment. I was noticing we
happened to be talking about the Medicare Advantage program and
I was just looking at the different providers, 289 of them in
Florida. Do they all have to agree to the prompt pay or to the
payment that Medicare prescribed to be able to offer that?
Dr. Wilson. One would assume.
Mr. Westmoreland. I would assume that, too.
Thank you, Mr. Chairman , for having this, and again we are
going through some procedural stuff right now, a little
disagreement, but I thank all of you for coming.
Chairman Gonzalez. I will tell you this right now; that we
are conducting ourselves like insurers on prompt payment.
Well, I think we're still going to make this vote, but I
would like the opportunity to go out there and thank you
personally. And Lynn, if you have a chance to also join me.
I will do something a little different and instruct staff
to get together. I want them to summarize some of the testimony
regarding identifying everything that everyone agreed on, and
what would be the remedy in order for us to share that with
other members of this subcommittee as well as the full
committee.
And I ask unanimous consent at this time, the members have
5 days to enter statements into the record. And this hearing is
now adjourned.
[Whereupon, at 12:00 p.m. The subcommittee was adjourned.]
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