How To Fight Discrimination In Managed Care

Author(s): 
By Stephen Monaco, DPM

Nothing makes us more angry and frustrated than discrimination based on participation and reimbursement levels. One of the classic examples is when we perform a bunionectomy and get reimbursed at a lower rate than an MD or DO for doing the same procedure. Indeed, the cost-cutting measures and restrictive practices of insurers make discrimination an everyday reality in our practices. Often, insurers will take advantage of our ignorance of the law to improve their own profit margins.
Are there any steps we can take to help ensure fair and equal payment for the services we provide to our patients? Yes, but the first step is to be cognizant of the various ways that discrimination can occur.
• Restrictions on plan participation. You may encounter restriction by geographic location where a plan only allows one DPM per zip code. There may also be restriction based upon certification criteria. For example, some plans may only accept DPMs who are certified by the American Board of Podiatric Surgery or those who have had two years of residency training.
• Limits on level of coverage. Perhaps you’ve been told by a plan that you’ll be reimbursed for forefoot surgery only or you may have seen certain codes with the phrase “are not paid when done by this type of provider.”
• Limits on benefits for podiatric services. Often, plans will equate “podiatric services” with “routine foot care” and exclude the services. You may also encounter plans that only allow foot surgery to be performed by an orthopedic surgeon.
• Different reimbursement levels for MDs or DOs for identical services. We’ve all seen examples of two fee schedules (one for podiatrists, one for orthopedists) for the same services. You may also notice that DPMs are on a “capitated” payment for a service whereas orthopedists are paid “fee for service” for the same procedure.
• Inconsistent payment amounts. Tracking your EOBs, you may notice regular, inconsistent payments for the same code (service).
Sometimes, procedures are not paid at the same time as other procedures or services you may have performed at the same visit. This may be the result of unfair unbundling software that doesn’t recognize certain modifiers. Some plans don’t recognize modifiers at all.

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