Newsletters

POSTED: February 28th, 2020
POSTED IN: EM Pulse - The Official Newsletter of MOCEP, January/February 2020,

I hope the new year is treating everyone well. It seems almost surreal that the holiday season is over and we’re in the thick of the legislative session. Of course, we’ve remained busy over the last few months so I thought I’d offer an update on some of our most pressing issues.

Arbitrary downcoding continues to be an issue. We recently sat down with the state director of Medicaid as well as Homestate, United Healthcare, and Missouri Care. I think the meetings were productive as we hopefully demonstrated, again, the flaws in their processes. Missouri Care stood by their claim that their computerized algorithm is validated and works well. Yet, they couldn’t explain why, if that were true, so many of the downcoded claims get overturned on appeal. They also claimed that the downcodes weren’t due to inaccurate coding but due to ‘fraud, waste, and abuse.’ Of course, they had no evidence to substantiate this claim or why the appeals process never mentions anything about fraud. The meeting with UHC went smoothly. They stated for Medicaid claims that they wouldn’t downcode due to final diagnosis as that wasn’t a good idea. Of course, they had no answer then why the commercial plans are going to start doing this in April. Finally, Homestate bluntly stated that they downcoded charts based on the final diagnosis, and they too, couldn’t explain why so many are overturned on appeal if their system is such a good one. Besides the absurdity of the system, we tried to demonstrate how it just adds extra cost and inefficiency. We are following up with the state director as well as having a lawyer put together a letter formally stating where we believe they are already in violation based on the meeting.

Of course, that is not the only strategy we have to stop downcoding. Although, we think this form of arbitrary downcoding is a violation of current law, and actually may leave the insurance companies open to fines, we have written legislation that would make it illegal for insurance carriers to downcode based on a final diagnosis without a formal chart review. This would not only prevent what the managed Medicaid companies are doing but also prevent commercial carriers such as UHC from doing the same thing. We believe that we have a sponsor in the Senate and are working to find one in the House.

At the same time, this is not the only issue that we are working on. The helmet bill fortunately was vetoed by the Governor last year but has already passed out of committee this year. We’ll of course continue to fight to make sure people wear helmets. Nurse practitioner scope of practice bills are always something on our radar. Fortunately, we haven’t seen any bad surprise billing legislation at the state level but will try to be proactive on this as the Federal Government continues to work on legislation. Finally, there are a number of other bills affecting reimbursement and prompt payment that we’re watching. We also are involved with proposed TCD legislation to ensure that unnecessary mandatory education is not added.

We plan to continue sending weekly updates about bills that are moving and important legislators to contact about them. Our annual Advocacy Day is being held in conjunction with the MSMA on March 3^rd and hopefully we’ll see some of you out there with us. Our general membership and educational meeting with elections will be held in Columbia on May 20. In the meantime if there are any issues that you’d like us to know about, please don’t hesitate to contact myself at [email protected] or our executive director at [email protected] or place a post on the engaged platform.

Sincerely,

Evan Schwarz, MD, FACEP, FACMT
President