Complying with preventive care rules under PPACA will be a major headache for doctors, insurers and employers…patients, time to get creative

The interim regulation for preventive services under PPACA are out. Remember during the health care reform debate that you heard all the talk about insurance company overhead and not spending enough of their revenue on health care.  Well these regulations and the administration of preventive services are going to add to those costs and to premium substantially.  Sure, you may not have to pay one penny for a cholesterol screening or your kid’s immunization, but you are paying one way or the other.  The rules appear simple, but the actual implementation by health plans, well, not so much.  If you have any experience in employee benefits, you will easily recognize the problems we are about to unleash.  

Keep these names in mind because they are going to determine what is and is not preventative, what goes on the list and comes off the list.  In addition, you can be sure that this group or that will be lobbying to add every conceivable service and product to the list of 100% covered preventive items.  

• United States Preventive Services Task Force (“Task Force”)
• Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (“CDC”)
• Health Resources and Services Administration (“HRSA”)

 What may appear simple is not so on closer look. We are setting up scenarios for patients to attempt to influence the billing and coding by providers.  We are encouraging “fraud.”  We are making life much more difficult for doctors and for those who process claims.  For employers, maintaining their plans to stay in compliance with these regulations will be on ongoing job because there is nothing static about the list of preventive services and there will be a need for constant communication with plan participants and for the updating of Summary Plan Descriptions. Because of the complexity of all this, there will be more controversy as to what was paid and how it was paid.  This will lead to increased claim appeals…thank heaven we have new regulations on internal and external claim appeals too. 

 Now, to illustrate the possibilities here are a few examples.  These examples come from the law firm of Davis & Harman LLP 

• If a “recommended” preventive service is billed separately from an office visit, then cost-sharing MAY be imposed with respect to the office visit only
     
• If a “recommended” preventive service is NOT billed separately, AND the primary purpose of the office visit is for such preventive services, then cost sharing may NOT be imposed with respect to the office visit
•  If a “recommended” preventive service is NOT billed separately, AND the primary purpose of the office visit is for a reason OTHER than the delivery of preventive services, then cost- sharing MAY be imposed with respect to the office visit 

An individual covered by a group health plan visits an in-network health care provider. While visiting the provider, the individual is screened for cholesterol abnormalities, which has “in effect” a rating of A or B in the current recommendations of the Task Force. The provider bills the plan separately for an office visit and for the laboratory work of the cholesterol screening test. 

• May impose cost-sharing on office visit because billed separately 
• Cannot impose cost-sharing on screening because constitutes “recommended” preventive services 

A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam described as part of the comprehensive guidelines supported by the HRSA. During the office visit, the child receives additional items and services that are not “recommended” preventive services. The provider bills the plan for an office visit and does not use separate billing. 

• Notwithstanding the fact that child received services other than “recommended” preventive services, the “primary purpose” of the office visit was for the delivery of “recommended” preventive services. Thus, the plan may NOT impose a cost-sharing requirement with respect to the office visit. 

An individual covered by a group health plan visits an in-network health care provider to discuss recurring abdominal pain. During the visit, the individual has a blood pressure screening, which has “in effect” a rating of A or B in the current recommendations of the Task Force. The provider bills the plan for an office visit and does not separately bill the blood pressure screening. 

• Even though no separate billing is used, plan/issuer may impose cost-sharing because “primary purpose” of office visit was NOT delivery of “recommended” preventive services

If you think you know what preventive services are, better read this from the regulations:

For the purposes of this analysis, the Departments used the relevant recommendations of the Task Force and Advisory Committee and current HRSA guidelines as described in section V later in this preamble. In addition to covering immunizations, these lists include such services as blood pressure and cholesterol screening, diabetes screening for hypertensive patients, various cancer and sexually transmitted infection screenings, genetic testing for the BRCA gene, adolescent depression screening, lead testing, autism testing, and oral health screening and counseling related to aspirin use, tobacco cessation, and obesity.

I think I need an aspirin.  Think of the conversations in the doctor’s office about how to get services covered at 100%.  Think of the opportunities to unbundle services to obtain a separate fee (how many doctors do you know who charge separately today to take your blood pressure?).  

Think about the cries of abuse if the insurance company or plan administrator denies a service the patient thinks is preventative or pays differently for the office visit and the cholesterol screening.  Think of the careful planning that will take place to be sure you have the correct “primary purpose” for the office visit.

 Ah, stop thinking you will end up with a preventive MRI.