Latest News and Updates

New Ohio Bill Seeks Medical Price Transparency

Gongwer News

November 14, 2017

Ohioans who need certain medical procedures would be able to get detailed cost estimates before undergoing the processes under legislation detailed by a House Republican on Tuesday.

Rep. Steve Huffman (R-Tipp City0 said the bill would impact procedures that require prior authorization, helping consumers shop for providers and facilities that might have lower rates.

The bill would succeed a related two-year-old law that has never been implemented due to an ongoing court challenge, he said.  That provision was included in a BWC budget bill (HB52, 131st General Assembly), and was challenged in court by a coalition of medical organizations.

Mr. Huffman, who chairs the House Health Committee, said patients, hospitals and physicians want transparency in the system, and the bill would help achieve that goal.

The cost estimates would require providers to offer a good-faith estimate of costs, including the expected cost to the patient and information about whether the provider is out of the patient’s insurance network.  Some patients, he added, trust their doctors and hospitals and won’t seek the information.

Regardless, the information would help patients make more informed decisions about their care, the lawmaker said.

Rep. Huffman said he envisions the process being implemented for procedures that don’t require prior authorization in the future.  He added that the bill doesn’t address emergency situations, and other cases when time might be of the essence.

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The bill is supported by the OHA and the OSMA both stating that it provides an appropriate level of expectation and responsibility on both the provider and the insurer.

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Rachel WinderNew Ohio Bill Seeks Medical Price Transparency

Ohio Bill on Tomosynthesis Coverage Receives Statehouse Hearing

Ohio Senate Bill 121, which would include tomosynthesis in the definition of screening mammography for insurance purposes, received its second hearing in the Senate Financial Institutions and Insurance Committee recently.  Below is an article that was included in a statehouse news publication, Gongwer, summarizing the hearing and the support the OSRS received from the medical community.  No additional hearings have been scheduled.  Let Chairman Hottinger know how tomosynthesis impacts your patients and ask for passage of Senate Bill 121.

Hottinger@ohiosenate.gov

Tuesday, October 3, 2017

Witnesses Support Bill Requiring Insurers To cover Mammogram Procedure

Doctors and provider groups urged a Senate panel Tuesday to back a bill that would require insurers to cover a new form of mammogram as a way to assist in the detection of breast cancer.

Victor Goodman, representing the Ohio State Radiological Society, told the Senate Insurance and Financial Institutions Committee that the state has required insurers to cover screening mammography since 1997.  The bill, SB 121, would require insurers to cover tomosynthesis as a part of breast cancer screenings.

He predicted opponents would likely say the bill imposes a new coverage mandate on insurers, but the General Assembly in the past acknowledged that new technology would be developed for mammography.

“This is not a new mandate,” he said.  “It’s something that’s been part of the Ohio Revised Code essentially since 1997.”

Dr. Bang Huynh, a radiologist with Columbus Radiology from Grant Hospital, said the tomosynthesis process, also known as 3D mammography, has improved detection rates.

“The reason cancer detection is so important is the earlier we are able to detect it, the better we are able to treat the patient,” he said.

Senator Bob Hackett (R-London) asked if the 2D mammography is always done first.

“You don’t have the option of deciding after you do the 2D whether to do the tomo or not,” he said.  Any subsequent test would be a diagnostic test, not a screening test covered as preventative care.

Senator Dave Burke (R-Marysville) said the General Assembly would be legislating how a procedure should happen at a physician’s office.

Dr. Huynh said he didn’t think of the bill as mandating what is being done in a doctor’s office.

“I don’t really see how this would force anybody to do anything that’s against their interests,” he said.

Senator Burke asked why an insurer would deny someone a procedure that could be potentially beneficial.

Dr. Huynh said until recently a lot of insurers were not covering tomosynthesis.

“I would ask them, why would not cover something that could be beneficial to patients?” he said.

Camille Grubbs, with Hologic, a manufacturer of breast tomosynthesis technology, said the technology is no longer considered experimental or investigational.

Judy Brandell, a nurse navigator at Mercy Health Fairfield Hospital, said in written testimony that insurance coverage of tomosynthesis and 3D mammography can be confusing for patients.

“Women are often confused and intimidated by their insurance coverage and the changes from year to year,” she wrote.  “So if the technologists and nurses don’t know for sure if they are covered, they end up declining due to potential additional and unknown costs.  From my perspective, it’s especially frustrating that the younger age range, who more frequently have dense and sometimes extremely dense breast tissue, will decline due to the inconsistency of coverage.”

The Ohio State Medical Association, Ohio Society of Radiologic Technologists, Ohio State University Medical Center and OhioHealth offered written testimony in support of the bill.

 

 

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Rachel WinderOhio Bill on Tomosynthesis Coverage Receives Statehouse Hearing

Ohio SB 121 to Include Tomosynthesis as Screening Mammography

Great news!! Legislation that was initiated by the Ohio State Radiological Society was introduced in Ohio today by Senator John Eklund (R-Munson Twp) to include “Tomosynthesis” as part of the required screening mammography benefits under health insurance policies.  Senate Bill 121 can be viewed at this link under “current version”.  https://www.legislature.ohio.gov/legislation/legislation-documents?id=GA132-SB-121

We will keep you posted as the bill is assigned to committee and advocacy opportunities are presented.

 

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Rachel WinderOhio SB 121 to Include Tomosynthesis as Screening Mammography

A Letter to Radiologists – past and future

Please take a moment to read this letter from one of your professions’ most passionate advocates and consider investing a little –  to help the future be as successful as the past.  Thank you, Dr. Olsen.

Donate Now

Letter to Current and Future Radiologists:

From: John Olsen Emeritus OSU Faculty member             johnolsen@columbus.rr.com

Dear Colleagues:

A few of you remember me. Many of you I haven’t met, but I was on the OSU Radiology faculty for 36 years, 1976-2012.  I am writing to share some thoughts but mostly to ask you to share your money with what I feel are very worthy supporters of your own well-being.  As institutions change and more radiologists become salaried employees, there is a tendency to think “the institution will look after me”, or “I can’t do very much relative to my situation anyway”.  I assure you that neither of these ideas could be further from the truth.

I want to make an appeal for and justification of organized radiology and organized medicine with the hope of encouraging your participation, even if that means as little as only paying dues and giving financial support. Your status in the Ohio State Medical Community and your position in the new payment systems depends mostly on two things, and one of these is not the Chairman’s negotiating ability, as important as that is.  The first is how well each of you is perceived as creating value here at Ohio State and the second is how well organized radiology both is and is perceived as a creator of value within the universe of medicine.  Many of you instinctively do all the right things to be valued consultants and helpmates to our patients and clinical colleagues.  For the rest of us, adapting the American College of Radiology (ACR) imaging 3.0 concepts can set us on the right course for the future.  Also, as a Department, employing data organized with ACR guidelines can aid in illustrating our value in the Health System.  The ACR has favorably shaped the economic environment of radiology practice to the benefit of all radiologists for over 60 years.  They also offer excellent training programs in leadership, management, business and human resources among others all designed for the busy radiologist.   I urge you to join the ACR and to contribute to the ACR Political Action Committee (RADPAC).

The egregious multiple procedure payment reduction, as an example, was not recently made less egregious because it was unfair but through intense lobbying of Congress. The recent budget resolution requiring computer order entry with decision support and not radiology benefit managers, is constructive for our specialty, but things like this do not happen by accident.

Here in Ohio, the Department of Health was about to adapt a policy promulgated by the Pharmacy Board that all radiology contrast would have to be injected by a physician and not by technologists.  This would have been disruptive to radiology practice, and it came down to the wire that the Ohio Radiological Society (ORS) was able to induce the Pharmacy Board to withdraw the proposal already agreed to by the Health Department over our objection. When you join ACR you also join ORS.

All government organs basically want to help, but any policy change or action has winners and losers, and it takes vigilance and money not to come out on the short end. Every one of us should contribute both to RADPAC and to the Ohio Radiology Society Political Action Committee (ORSPAC) for which you have an addressed stamped envelope.  Soon online contributions will also be possible.  Every member of Columbus Radiology (Grant Hospital) contributes regularly to both RADPAC and ORSPAC.  The ACR knows them well as one of the groups with 100% participation.

The Pharmacy Board success described above was achieved by our attorney Victor Goodman who has been essential for much of our success. Victor and his colleague Rachel have relationships with most of the Ohio Government such that much of what might affect Radiology is communicated to them well before getting to the proposal stage.  Their service has been invaluable through the years but it is not free, and were it not for our historical relationship such effective help might be beyond our means.  Victor and Rachel are paid out of the ORS legal budget.  Rachel manages ORSPAC but ORSPAC expenses are also in the legal budget.  All contributions to ORSPAC go to supporting legislators, judges and candidates favorable to radiology to assist in their elections.

As the ACR is our political and socioeconomic organization, the Radiological Society of North America (RSNA) is our scientific organization. Both RSNA and ACR are among the most effective organizations in organized medicine, and we are truly blessed to have them and the great leaders who created and continue to recreate them.  I wish all radiologists belonged to both.  I want to make an appeal for the Research and Education Fund of the RSNA.  Before creating this fund Radiology was at a serious disadvantage.  The public could identify with Heart Disease, Cancer, Arthritis, etc., so the respective organizations had an easier path for fundraising, but no one suffers from or dies of Radiology.  Radiology was several generations behind most of medicine in terms of raising money to fund research. The Research and Education Fund has been an amazing success but needs continuous ongoing support.  Grants from the fund have been multiplied forty fold by grantees obtaining additional funding from other sources such as the NIH.

Radiology has been good to me and my family, so I continue to support the future of Radiology, but we should all advance the future of our specialty by contributing generously to the Research and Education fund of the RSNA.

I have unashamedly just asked you to give away (invest) more than a little money.  I would like to provide some not intuitive money wisdom.  Long term department members might inform the younger and newer that I do have some knowledge in this area.    Money has an amazing property.  No matter how much you have or make, it will never be enough until you are giving some away.   Anyone who tithes can tell you that giving creates inner financial peace and actually enhances your ability to enjoy life that spending cannot compare with.  You will not miss what you give and what givers have left becomes enough. (This magic only works with what is freely given and not what is surrendered to coercion which has a different effect).

Please support yourself and Radiology by joining ACR which includes ORS and supporting RADPAC (National) and ORSPAC (Ohio) and joining the RSNA and supporting The Research and Education Fund. If you follow your money with active participation, so much the better.

Your support for all or any of the above would be of great benefit to yourself and your field but this is only part of the story.   There are broader issues requiring attention. The Ohio State Medical Association (OSMA) has been essential to the well-being of all Ohio citizens and physicians.   This includes for example dealing with unfair practices of medical insurance companies, guiding legislation and medical malpractice and tort reform.   The favorable malpractice climate in Ohio is the direct result of intense work by OSMA members and staff even including electing Ohio Supreme Court justices who interpret the law rather than legislate law from the bench. (In fact losing several favorable justices on the Ohio Supreme Court next November could undo 15 plus years of successful effort and renew the malpractice crisis.)

I would like to describe an episode mostly known only to those who deal with medical billing where only OSMA was able to fix a serious problem. Since the start of Medicare, Ohio Medicine had constructive relationships with Nationwide and then with Palmetto as our Medicare insurance carriers.   When CGS became the carrier they brought incredibly backward business methods that compromised physician payments and they were callously unresponsive to physicians and their representatives.  In addition, the Medical Director seemed to have a particular animus towards Radiology.  Because of the CGS performance, OSMA enlisted our senators Sherrod Brown and Rob Portman to arrange a meeting with Kathleen Sibelius the then Secretary of Health and therefore head of CMS (Centers for Medicare and Medicaid services) to discuss the Ohio situation.   CGS was ordered to correct all deficiencies or lose the Medicare contract.    CGS  immediately modernized their business practices, and they also replaced the Medical Director who was antagonistic to Radiology.  The new Directors Dr. Earl Berman for Part B and Dr. Michael Montijo for Part A are excellent leaders, supportive of physicians and working hard to make the system work well for all three constituents, patients, physicians and the federal government.   Radiology could not have resolved this issue, only OSMA representing all Ohio member physicians could succeed.

An anecdote… The Ohio Radiological Society and the radiologists of Kentucky (the other CGS state) worked together on our particular CGS problem to share costs, demonstrate solidarity, and avoid duplication of effort.   During the joint OSMA/ CMS discussions with CGS, at one point CGS claimed that all the problems were unique to Ohio.  OSMA soundly refuted CGS based on the ORS work with Kentucky…. And this ended the last shred of CGS credibility.

OSMA performs valuable service to the medical community but as more physicians become salaried (over 50% as of two years ago) the membership of OSMA is declining.   OSMA is just as important for salaried physicians but the value is not yet as well recognized.  Also declining are contributions to the OSMA political action committee (PAC).  Last year the Nursing Association PAC raised 40% more money than the physicians which is not a good situation as nursing continues to lobby the legislature to allow more encroachment on the practice of medicine.    The Trial Lawyers Association PAC which works to undo our favorable Ohio malpractice situation has 60% more money than OSMAPAC.

Two years ago in a major policy change implemented in hope of increasing physician participation, it was no longer required that OSMA members also join the local county medical society or that local members join the State. Our local society, years ago known as the Franklin County Academy of Medicine and now called the Columbus Medical Association (CMA), performs valuable services to the community.  While many physicians participate in various specific programs, most of the leadership function is provided by about 25 physicians eager for your help.  CMA programs such as the Free Clinic are worthwhile and a great way to meet other physicians and serve your community.  Resident and medical student participation is welcome as it is in the RSNA and ACR/ORS.

Dr. Rick Nelson in Emergency Medicine is very active in both organizations and would be happy to provide a more complete and up to date perspective but these organizations are important to the health of medicine, and a strong OSMA is especially important for Radiology.

Please remember your contributions to ORSPAC, RADPAC and the Research and Education fund of the RSNA and join the respective organizations if not already a member.   Also please give thought to joining and supporting at least one of the non-radiology organizations.

A review of Ohio Radiological Society achievements would include:

When Ohio Medicaid was revised by Governor Kasich we negotiated favorable terms for radiology that avoided most of the cuts experienced by other providers.

In the recent Breast Density Legislation, we Influenced the bill language and composed the wording of the patient notification letters even though we opposed the legislation as an intrusion on medical practice.  We made the bill as innocuous as possible and excluded it from being the basis of any malpractice action.

Successfully maintaining the Ohio Department of Health’s education and training standard for all applications of therapeutic radiation.  (Same as the Nuclear Regulatory Commission standard.)   Dermatology was asking for a dispensation from the rules so they could use their own in office equipment to employ therapeutic amounts of ionizing radiation to treat patients with skin cancer without obtaining the requisite training, and had garnered some political support to allow this.

Radiology Assistant Legislation defining practice guidelines and disallowing independent practice.  This in response to a legislative proposal to recognize Radiology Assistants as independent practitioners.

Telemedicine Legislation requiring an Ohio Medical License for out of state practitioners providing services to patients located in Ohio.    (Several legislators consistently referred to this bill which affects all Ohio Medicine as the “Radiology Bill”)

Legislation requiring that hospitals billing globally for screening mammograms must actually pay the agreed payment to the radiologist.  Bill also separately required additional payment for digital mammography and CAD.

Regular interaction with State Agencies, OSMA and Medicare and “ad hoc” with legislators and other organizations.

Legislation allowing patient self- referral for Screening Mammograms at a time when Ohio law required physician referral for all ionizing radiation.  This included Ohio adopting the ACR’s MQSA standards well before they were a Federal requirement.

Legislation requiring the licensing of Radiology and Nuclear Medicine technologists and assisting the Ohio Department of Health in writing and maintaining the resultant rules.

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Rachel WinderA Letter to Radiologists – past and future

Radiation Advisory Council Saved Upon Signature of Governor Kasich

We were reminded of an important lesson this month to never take your eyes off of the legislature. 

In an effort that we organized back in May which we believed had saved the Ohio Radiation Advisory Council (RAC) from sunset against the formal testimony of the Ohio Department of Health, instead, was only a temporary solution as the RAC was moved back to the “sunset” column during the craziest of legislative seasons, known as Lame Duck Session.

We quickly went to work and with the help of Dr. Paul Geis and Dr. John Olsen among others, we put on a full court press.

We are proud (and relieved) to announce that Ohio Governor John Kasich signed House Bill 471 this week that formally and statutorily retains the Radiation Advisory Council.

See the pertinent language here:  HB471 RAC Retention.

It is the efforts of your peers and your advocates at the Ohio State Radiological Society that are directly responsible for making sure that the issues impacting your industry are prioritized within the Ohio Department of Health.

Congratulations and thank you for your continued support of the OSRS.

 

 

 

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Rachel WinderRadiation Advisory Council Saved Upon Signature of Governor Kasich

Providers Required to Bill Medicaid Managed Care Plans in 2017

Starting in January 2017, Ohioans will now be able to access their Medicaid benefits through one of Ohio’s five statewide Managed Care Plans. Once enrolled in a Managed Care Plan, providers will no longer be allowed to bill the state and instead will be required to bill the plan directly. Providers who do not have contracts with the Managed Care Plans may be able to provide services to current patients/clients for a “transition period”.

Beginning January 1, managed care will be mandatory for Medicaid eligible individuals enrolled in the Breast and Cervical Cancer Project (BCCP) program, children in custody (foster care) and adopted children & individuals enrolled in the Bureau of Children with Medical Handicaps (BCMH) program.  Enrollment will be voluntary for individuals enrolled in any of the home and community based waiver programs administered by the Ohio Department of Development Disabilities.

The Ohio Department of Medicaid began sending informational and enrollment notices to members who are not currently enrolled with a Managed Care Plan in August 2016.

For more information about contracting with the Managed Care Plans or how to submit claims, contact the plans’ provider services with questions at the numbers below or by visiting the following link:

http://medicaid.ohio.gov/PROVIDERS/ManagedCare.aspx.

Managed Care Plan Toll Free Provider Services Phone Number Managed Care Plan Website Address
BUCKEYE 1-866-296-8731 www.buckeyehealthplan.com
CARESOURCE 1-800-488-0134 www.caresource.com
MOLINA 1-(855) 322-4079 www.molinahealthcare.com
PARAMOUNT 1-888-891-2564 www.paramounthealthcare.com
UNITEDHEALTHCARE 1-800-600-9007 www.uhccommunityplan.com
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Rachel WinderProviders Required to Bill Medicaid Managed Care Plans in 2017

Rep. Latta Supports the USPSTF Transparency/Accountability Act

  • Thank you Congressman Latta for agreeing to co-sponsor H.R. 1151, the USPSTF Transparency and Accountability Act.
  • USPSTF recommendations were originally created for the purpose of providing supplemental guidance to primary care physicians. Following the passage of the Patient Protection and Affordable Care Act, USPSTF recommendations gained a significantly more prominent role in the determination of Centers for Medicare and Medicaid Services’ coverage decisions and in the establishment of preventive service coverage requirements for private insurers. With such substantive policy issues at stake, the public trust demands that the USPSTF recommendation-development process be entirely transparent and consistent with other federal agencies that create policy and promulgate regulations.
  • Many in the research and medical community believe that the Task Force should embrace the public transparency and accountability protections mandated on traditional government agencies under the Federal Advisory Committee Act (FACA) and the Administrative Procedures Act (APA) and be required to:
    • Be transparent in its methodology
    • Disclose the input it received as part of its public comment periods and explain its analysis of the public comments
    • Provide rationale for accepting or rejecting the input provided by the public
  • There is no better example of the negative consequences of the USPSTF’s current recommendation process and the need for the enactment of H.R. 1151/S. 1151 than the USPSTF’s 2009 and 2016 screening mammography recommendations. These discredited recommendations clearly demonstrate why critical decisions affecting citizens’ access to preventive healthcare services should not be made behind closed doors without the benefit and protection of well-established federal agency transparency requirements.
  • The American College of Radiology is seeking dissolution is seeking a more deliberative, science-driven, transparent and publically accountable process. ACR acknowledges that, procedural issues notwithstanding, at times, USPSTF recommendations appropriately reflect the available evidence and are consistent with the predominant view/assessment of the scientific community. For example, in December 2013, the USPSTF issued a new, higher Grade of “B” to annual LDCT scans for patients who have a long history of heavy smoking and, thus, are at a higher risk of developing lung cancer. This recommendation has resulted in Medicare and private insurance coverage of LDCT exams and will undoubtedly save thousands of lives.
  • ACR urges Congress to enact bipartisan legislation which comprehensively reforms the USPSTF’s membership, research methodology, and public comment process.
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Rachel WinderRep. Latta Supports the USPSTF Transparency/Accountability Act

Cigna First National Insurer to Cover Tomosynthesis as Screening Mammography

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This is great news that we are hopeful turns into a trend among other insurance providers.

In Ohio, the Ohio State Radiological Society (OSRS) is working with the Ohio Department of Insurance and state legislators to bring attention to this issue.

We have taken the position that tomosynthesis should already be covered under the current definition of “screening mammography” in the Ohio Revised Code which is as follows:

“Screening mammography” means a radiologic examination utilized to detect unsuspected breast cancer at an early stage in an asymptomatic woman and includes the x-ray examination of the breast using equipment that is dedicated specifically for mammography, including, but not limited to, the x-ray tube, filter, compression device, screens, film, and cassettes, and that has an average radiation exposure delivery of less than one rad mid-breast. “Screening mammography” includes two views for each breast. The term also includes the professional interpretation of the film. “Screening mammography” does not include diagnostic mammography.

The key words are “including, but not limited to”.

Other insurance providers that are currently covering Tomosynthesis, of which we are aware, include:

  • All Ohio Medicaid/Medicare Providers
  • Aultman Health
  • ProMedica (Paramount Health Plan)
  • Summa Health System (SummaCare)
  • Cigna

Those providers that are denying coverage state the reason is that the technology is “investigational”.

However, the American College of Radiology (ACR) has determined that tomosynthesis is no longer investigational and CMS agrees along with many private insurers across the country.

From Cigna’s Medical Coverage Policy on Screening Mammography:

Digital Breast Tomosynthesis (DBT)

Large prospective and retrospective trials demonstrate the use of screening digital breast tomosynthesis (DBT) (3D mammography) in addition to 2D screening mammography (i.e., 2D) when used for annual screening provides a statistically significant increase in cancer detection rates (including invasive cancers) and a statistically significant decrease in recall rates compared to 2D mammography alone. Although long term studies on survival are lacking, it is reasonable to postulate from large prospective and retrospective trials that the addition of DBT may confer a positive impact on mortality. (emphasis added)

And finally, studies show that adding Tomosynthesis to 2D mammography is actually cost-effective to payers.

HealthImaging (8/23, Pearson) reports, “Adding annual screening tomosynthesis to 2D mammography beginning at age 40 is cost-effective compared with 2D mammography alone,” researchers found. The study, which “incorporated data from a multi-institutional study of more than 450,000 patients, institutional data of 13,000 patients, literature values and Medicare reimbursement rates,” revealed, however, that “net monetary benefits of the extra exam are around three times greater for women in their 40s than for those in their 50s and older.” The findings were published online in the American Journal of Roentgenology.

What are your experiences with Tomosynthesis?  Do you cover the costs?  Do patients have the option to pay out of pocket?  Are insurers paying?  Help us advocate for you by sharing your story.  rwinder@beneschlaw.com; @OhioRadSociety; https://www.facebook.com/OhioRads

 

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Rachel WinderCigna First National Insurer to Cover Tomosynthesis as Screening Mammography