Staying Strong in the Face of Unfair Policy: How to Fight and Win with Dr. Kathy Cain
Topeka PediatricsTopeka, KS
Staying Strong in the Face of Unfair Policy: How to Fight and Win with Dr. Kathy Cain
Topeka PediatricsTopeka, KS
When Dr. Kathy Cain saw an unfair insurance policy was reducing payment for her services in her home state of Kansas, she did not take it lying down.
When Dr. Kathy Cain saw an unfair insurance policy was reducing payment for her services in her home state of Kansas, she did not take it lying down. Instead, with the help of her physician networks, Cain was able to change the policy over years after a long search for her voice to be heard. This article provides a quick primer on medical coding and its potential manipulation, as well as a brief background of one of the major market leaders in the healthcare insurance industry and how one woman took them on—and won.
When Dr. Kathy Cain began her training as a pediatrician, she focused on acquiring the knowledge she would need to diagnose and treat her young patients. Little did she know at the time that after establishing her practice Topeka Pediatrics in 2001, she would be forced to take a crash course in the business of health insurance.
When vaccine administration codes were created in her home state of Kansas, Dr. Cain immediately noticed she was not being paid by their state-level Blue Cross Blue Shield (BCBS) for the work she was doing. “What it really comes down to is that BCBS of Kansas (BCBSKS) was redefining billing codes so as not to have to pay pediatricians for the administration of vaccines,” explains Cain. “Figuring out how to fix this problem was a journey, to say the least.”
“Many pediatricians, especially those in private practice, go into the field because it is a true calling. I knew I wanted to be a pediatrician from a very young age. I had my own wonderful pediatrician growing up in Topeka, Kansas. He was extremely personable and used humor to make his small patients feel comfortable with his hilarious Donald Duck impressions,” recalls Cain fondly. “I saw what he did for the children in his care, and I thought, ‘I want to be that someday.’ Unfortunately, I did not, nor do most aspiring pediatricians, ever receive any formal education on the business side of things, particularly on how to deal with insurance companies and other payers. The lack of training on these matters can leave us at a disadvantage.”
“Healthcare providers deserve to be paid fairly for what they do, and unfortunately that sometimes means going head-to-head against these corporations for payments they really don’t want to make. Learning to work with insurance companies is essential to your livelihood as an independent physician, so you can keep your practice doors open,” says Cain. “It’s just a fact that good business is good medicine. Sometimes going up against large insurance companies to receive payment for treatment given really feels like a David and Goliath situation. Still, when I saw what was going on in my home state, I knew I had to do something to change a bad policy.”
“It’s just a fact that good business is good medicine. Sometimes going up against large insurance companies to receive payment for treatment really feels like a David and Goliath situation. Still, when I saw what was going on in my home state, I knew I had to do something to change this egregious policy, because if pediatricians can’t stay in business, then no one will be there to take care of the kids.”Dr. Kathy Cain
A Quick Primer on Coding
Coding is the process by which physicians communicate to a payer which services were rendered to the patient and why. There are diagnostic (ICD or International Classification of Diseases) codes that describe why a patient was treated and procedural (CPT or Current Procedure Terminology) codes that tell what services were provided to the patient as part of the treatment. There is also a Healthcare Common Procedure Coding System (HCPCS) which is a set of codes used to describe things not covered by other codes, such as durable medical equipment, ambulance services, or certain medicines. All of these codes are set and standardized by the American Medical Association (AMA).
In order to receive payment for the treatment administered, providers have to enter in the appropriate set of codes for why the patient was seen and what tests or treatments were given. There are codes for products like vaccines, but then there are also codes for the administration of these vaccines, which includes educating parents and patients about any vaccines given, getting consent, and giving the shot to the patient, which can take upwards of 15 minutes or more. “What is happening with the BCBSKS coding is like having a carpenter build something for you and only paying them for the wood, but not the nails or the labor. You can’t deliver the actual vaccine without the administration part of things,” explains Dr. Cain. “We were being asked to eat that cost.”
“Sometimes it [the insurance industry] feels like a maze purposely designed to reduce fair payment, especially for independent physicians and particularly for specialties like pediatrics with smaller profit margins.”Dr. Kathy Cain
Independent Physicians Left Vulnerable
Medical coding, billing, and payment are a complicated business that requires specialized training to reach expertise. Says Dr. Cain, “Sometimes it feels like a maze purposely designed to reduce fair compensation, especially for independent physicians and particularly for specialties like pediatrics with smaller profit margins. Physicians who are employed under a healthcare system or hospital don’t typically have to worry as much about fair compensation around coding manipulation by insurance payers. They have leverage with insurance companies because they are a part of a big health care system that the insurance company can’t do without. Usually, the system that employs physicians and healthcare workers has negotiated with insurance companies to provide fair payment for services.”
A Problematic History
The issue Cain was seeing stemmed specifically from Blue Cross Blue Shield of Kansas (BCBSKS), but other state-level BCBS plans have caused similar frustrations for providers. Says Cain, “BCBSKS does not pay for many things that might be considered standard by other payers. For example, they will not pay for a sick child visit and a well-child visit simultaneously, which creates hoops for doctors and parents to jump through if you go for a well-child visit and end up having an illness or injury to treat as well. There is also an issue about receiving payment for developmental, autism, and mental health screenings. If you look closely at BCBS state-level plans, there is a long history of problematic behavior, which stands out, particularly because BCBS state-level companies began, and many still claim to be, not-for-profit organizations.”
Here Cain refers to the fact that BCBS was originally founded in the 1930s as a fully not-for-profit organization whose mission was to make sure all communities had access to medical care and to safeguard families against financial ruin due to unforeseen health problems. However, in 1994, BCBS began, “giving its franchises the option to convert from non-profit charities to for-profit companies,” according to a report by Nation Public Radio (NPR). For some onlookers, this move may have caused a conflict of interest that adds another layer of complication to the already labyrinthine workings of the American healthcare insurance industry.
Although BCBS of Kansas attempted to affiliate itself with a for-profit insurance provider in 2001, that effort was blocked by the Kansas State Insurance Commissioner and a group of other concerned parties such as the Kansas Society for the Medically Underserved. Despite this ruling, many providers feel that some state-level BCBS insurers are operating in a way that appears profit-driven and leads to unfair payment of legitimate claims and services provided by physicians.
A Pivotal Discovery
“In many cases, there is nothing the provider can do to be fairly compensated for some services when insurance companies have decided not to pay,” explains Cain. “However, in this case, there was something that could be done because the action of modifying the definition of the CPT code amounted to a Health Insurance Portability and Accountability Act (HIPAA) violation.”
Dr. Cain tried several times to get the unfair vaccine payment rule changed. Initially, the American Academy of Pediatrics (AAP) wrote a letter to BCBSKS describing the correct use of the vaccine administration codes, without success. A few years later the AMA, which owns CPT codes, sent a letter to BCBSKS to cease and desist from using the incorrect codes, but BCBSKS continued using the codes as before. Finally, after Cain had almost given up hope that the issue would be resolved, Cain and a colleague were directed to the complaint area on the Centers for Medicare and Medicaid Services (CMS) website that allowed providers to submit complaints regarding possible violations under HIPAA Administrative Simplification provisions. These provisions, according to the AMA, “ensure consistent electronic communication across the U.S. health care system by mandating use of standard transactions, code sets, and identifiers.”
A Long-Awaited Change
After submitting the complaint about the code change initiated by BCBSKS to the CMS website on February 9, 2022, Dr. Cain was pleasantly surprised that the ball began moving. Physicians in Kansas had dealt with the problem of the redefined CPT code blocking payment for years, but had always been ignored. With the discovery of the potential for CMS involvement, Dr. Cain had finally found an outlet for her voice and those of her frustrated colleagues. In March of 2022, Dr, Cain received an email from a representative from CMS’s National Standards Group (NSG) that after reviewing the complaint, they found that it did have merit, but that BCBSKS was denying any wrongdoing. According to the statement issued by BCBSKS in response to CMS, “BCBSKS does not believe our approach violates the letter or the spirit of these regulations.”
CMS on its own had no authority to govern the actions of the AMA, the entity that defines the codes. Fortunately, CMS had a letter from the AMA dating back to 2017 that outlined their stance and suggested that the BCBSKS policy may stand in violation of HIPAA laws. The AMA letter stated the following:
The policy may be in violation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) implementing regulations that require physicians to report the CPT code version that is valid at the time the health care service is furnished. The AMA urges BCBSKS to immediately update its coding systems, related policies, and communications to utilize the current CPT code descriptors.
With this statement from the AMA in hand, CMS reached out a second time to BCBSKS to urge the state-level insurer to reconsider its policy.
In a letter dated April 1, 2022, BCBSKS sent a letter to CMS saying they would initiate a corrective action plan to rectify the situation and to begin following the AMA-approved CPT code definitions. After such a long waiting period, Dr. Cain was astounded at the swift about-face performed by BCBSKS once CMS got involved. “I would urge any physician or healthcare worker that if you see something that looks wrong, say something. You should feel empowered to report anything you suspect may be a HIPAA violation to the highest authority you can. Eventually, someone will listen.”
“I just want to let other physicians in private practice know that it is possible to go up against the big guys and change bad policy. By working together, we can ensure fair compensation for ourselves and for the future.”Dr. Kathy Cain
Strong Networks for Strong Medicine
“As independent pediatricians, often we must take on problems that our medical training did not prepare us for. That’s when the support of your colleagues and being plugged into the right networks comes in,” says Cain. “I would not have found the solution to this problem without the help of the American Academy of Pediatrics, our fearless Payer Advocacy Advisory Committee [PAAC], AAP staff, and my [The AAP’s] Section on Administration and Practice Management which has been a sounding board for all pediatric business challenges for me over the last 20 years.”
While this coding change initiated by Dr. Cain marks a win for healthcare providers, the fight against unfair insurance policies is far from over. Dr. Cain has recently retired from her Topeka practice and moved to Colorado for a well-deserved rest in the mountain air. “It’s a shame that oftentimes insurers seem to spend more time and money figuring out how to not pay for things than they would have spent just honoring the claim,” laments Dr. Cain, but with a caveat. “I just want to let other physicians in private practice know that it is possible to go up against the big guys and change bad policy. By working together, we can ensure fair compensation for ourselves and for the future.”
As Dr. Cain emphasized, if you or your staff sees an unfair policy depriving your practice of payment, it is essential to be your own advocate. Contact your state AAP chapter, CMS, the AMA, PAAC, or SOAPM to get started.
Allyson Howard is a firm believer that well-crafted stories can redefine brands and organizations, reinvigorate internal and external business communications, and engage and inform consumers in groundbreaking ways. Her BA in English and Education from the University of Iowa, as well as her MS in Professional Writing from NYU, have positioned her to create a wide range of content tailored to communicate unique brand voices and messages. She lives outside Chicago with her family and enjoys cooking for loved ones and reading.
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