Problems Plague Controversial Highmark Program
Disastrous PMMP delayed yet again due to complaints and errors
Harrisburg, PA 12/28/12 – The Pennsylvania Chiropractic Association (PCA) today announced that it has learned that Highmark Inc.’s controversial Physical Medicine Management Program (PMMP) has again been delayed due to the efforts of PCA and others, with full implementation now pushed back until May, 2013. PCA has been fighting against the PMMP because of its extraordinary violation of healthcare patients’ rights of choice and other negative impacts upon physical medicine providers and patients’ access to medically necessary care. Read more.
State’s Chiropractors Urge Highmark to Dump PMMP
Highmark program causing widespread problem that limit patients’ choices & treatments
Harrisburg, PA – Oct. 22, 2012 – Officials from the Pennsylvania Chiropractic Association (PCA) today released a letter the Association sent to Highmark this week urging the healthcare insurer to immediately drop its controversial and flawed Physical Medicine Management Program, or PMMP, in the wake of hundreds of complaints from physical medicine providers and their patients.
‘Soft-launched’ in September by Highmark, the PMMP program utilizes a computer software program to determine whether a patient is eligible for insurance coverage for physical medicine services, and if so, how many treatments the patient may receive. The ill-advised program removes doctors and physical medicine providers from the equation in determining patient treatments, and eliminates patient choice in seeking physical medicine therapies.
Schatzberg said PCA has two ‘requirements’ that must be met by Highmark before the group will continue talks with the insurer, including:
1.Terminate the flawed PMMP program immediately. 2.Convene a meeting with physical medicine providers to address Highmark’s over-billing concerns and develop mutually-acceptable alternatives to PMMP that targets those at fault, rather than penalizing every physical medicine provider in the state.
“Since the September launch of PMMP, our offices have been inundated with complaints from both chiropractors and their patients,” said Dr. Daniel Schatzberg, president of the PCA, the state’s largest professional organization for the chiropractic profession. Schatzberg said Highmark officials recently contacted PCA to arrange another meeting with Highmark officials to discuss the program. “We have met with Highmark officials in the past to discuss PMMP, only to be given the run-around. Hence our decision to oppose the PMMP program and work to prevent its full implementation,” said Schatzberg.
“To date, Highmark has not responded in any favorable way to our concerns, nor has it addressed the myriad problems being experienced by the company itself with the implementation of the PMMP program,” said Schatzberg. “PMMP is a poorly-designed and badly conceived effort to limit patient access to chiropractic and physical medicine services, and its time Highmark admit it made a mistake with this and move on.”
“We have no problem sitting down with Highmark’s officials to discuss PMMP,” said Schatzberg, “but we’re not going to stand for lip-service or empty promises from them. The issue, according to Highmark, is that some physical medicine providers are over-billing for services. Even though Highmark already has a process in place for identifying and punishing those who do so. Now, with PMMP, Highmark wants to penalize every doctor or provider because of the actions of a few. This is wrong, and everybody from senior Highmark officials to the state Insurance Commissioner and our legislators knows it. “
Schatzberg said PCA officials and those from other physical medicine provider associations are willing to meet with Highmark, but insist Highmark show good faith by first suspending the problem-plagued program: “We’re not going to waste our time meeting with Highmark unless they take substantive action to suspend this ill-advised effort,” said Schatzberg. “PMMP is arguably one of the worst ideas to ever be forced onto consumers, and Highmark’s senior officials should have the common sense to understand this.”
Click here to read PA Chiropractic Association's Letter to Dr. Donald R. Fischer, senior vice president and chief medical officer for Highmark Inc
Problems Force Another Extension of Highmark PMMP ‘Soft’ Launch
Insurer delays start-up until December, State Insurance Dept. says it can’t stop program
Harrisburg, PA 10/1/12 – Highmark Inc. announced late last week that it is again extending the so-called ‘soft’ launch of the controversial Physical Medicine Management Program (PMMP) for an additional 90-day period through the end of 2012. While the company provided no substantive reason for the delay, physical medicine practitioners across the state report numerous problems with the program and complaints continue to pour in. Officials from the PA Chiropractic Association (PCA), which has been in the forefront of opposition to the ill-advised program, also report that PA State Insurance Department Commissioner Michael Consedine indicated in a recent meeting that his office is unable to stop the implementation of the program because of the lack of laws or authority allowing such action.
“We are pleased that Highmark is “delaying’ the official launch of PMMP,” said PCA President Dr. Daniel Schatzberg. “For months we have been urging Highmark and our state officials to abandon this poorly-conceived and administered program, and Highmark’s continuing delays underscore the problems that are occurring with it, although they will never admit it. We humbly suggest that Highmark admit it made a mistake with PMMP, and abandon this effort once and for all.”
Schatzberg also noted that officials from PCA recently met with State Insurance Commissioner Michael Consedine, who said his department has little discretion or ability to do anything about Highmark’s proposed PMMP because of limitations in state law. “Unless Highmark’s transgressions fall under the strict guidelines of the Unfair Insurance Practices Act, the state’s hands are tied with regard to PMMP,” said Schatzberg. “While the state has been cooperative and shares our concerns, by law they are prohibited from taking action at this time. But they will be monitoring the situation closely and could take action if consumers begin complaining.”
Schatzberg also lauded the efforts of State Representative Bud George (D-74th), who is currently seeking legislative support for a state house resolution opposing Highmark’s use of PMMP. “Many of our elected officials are strongly opposed to Highmark’s actions,” said Schatzberg, “and we will continue to pursue a legislative solution to this problem if the State Insurance Department cannot act, or if Highmark itself insists upon pursuing this ill-conceived plan.”
Highmark’s controversial PMMP plan is being vigorously opposed by chiropractors and physical and occupational therapists across the state, who understand that the experimental program is deliberately designed to remove medical professionals, such as chiropractors and therapists, from the decision-making process that determines the need for “medically necessary” services for patients presenting problems. PMMP relies upon a flawed and unproven software program that decides if a patient is eligible for treatment and, if so, how many treatments a patient may receive.
Schatzberg said the state’s chiropractors are encountering a substantial number of problems with the program, which they raised during their meeting with Consedine, including:
- Patients are limited to only 8 visits per year unless costly and time-consuming paperwork is filed by the provider – Highmark is essentially forcing doctors to become unpaid insurance administrators for the company, thereby cutting Highmark’s costs while increasing the workload and expense for medical professionals
- Patients who seek treatment from a participating Highmark provider may be denied treatment, but if that same patient goes to a non-participating provider, the treatments will be allowed.
- Patients may not change providers for a year once they have been registered in the PMMP program, nor may they have two providers at the same time – such as a chiropractor and a physical therapist. Even if both are needed.
“These are certainly unwarranted and unethical infringements into the doctor-patient relationship that compromises the basic freedom of choice that all patients should enjoy. This also has far-reaching implications for patients’ access to healthcare services and their personal health and well-being,” said Schatzberg. “If Highmark is allowed to proceed with PMMP, patients will either have to pay more for their care out of their own pockets, or stop treatments altogether and simply live with Highmark-inflicted and completely preventable pain.”
“The reality is that Highmark is reducing or putting a cap on coverage for patients, in violation of their existing agreements, while still charging higher rates. Nor is PMMP being consistently applied as some groups are routinely included in the PMMP program while others are not. Highmark’s intentions, policies, instructions, consistencies and technical capabilities are all highly suspect with regard to PMMP.”
Schatzberg said the state Insurance Department’s inability to stop Highmark’s PMMP, while permitting a large and unnecessary rate increase that will only add to Highmark’s existing $4 billion in reserves, “is disappointing and contrary to the best interests of Pennsylvanians insured by Highmark.”
“The absence of regulatory or enforcement action by the state’s top insurance watchdog leaves the PCA and other physical medicine practitioners with the courts or the state legislature as our only avenues of recourse in the matter,” concluded Schatzberg.
Highmark Extends PMMP “Soft Implementation” to 12/31/12; Attack on Physical Medicine Patients & Professionals Expected to Intensify
Contact: Edward Nielsen, Executive Vice President at 717-232-5762
As a result of an intense meeting between PCA’s Highmark Working Group and the PA Insurance Department on 9/24/12, the attached was received late afternoon of 9/27/12, noting that Highmark’s PMMP “soft implementation” was extended until 12/31/12. The 9/24 meeting was facilitated by State Representative Steve Barrar and also attended by Gail Reinard, legislative director for Senator Chuck McIlhinney (sponsor of SB1391- Fairness in Co-Payment Act).
Pennsylvania Doctors of Chiropractic should in no way view this as a victory.
Instead, PCA expects the matter to intensify as the battle lines are more clearly drawn pitting a profit-obsessed Highmark against physical medicine patients, employers, DCs, PTs and other physical medicine professionals. To that point, PCA President Dan Schatzberg, D.C., said “It is vitally important that all chiropractors continue to learn as much as they can about Highmark’s PMMP, especially navigating their way through the outrageous administrative hassles and burdens placed on physical medicine professionals that have now soiled what little credibility Highmark might have had prior to their PMMP. This is one of Highmark’s many ‘Achilles Heels’ in this ill-advised, fundamentally flawed and very poorly executed program.”
PCA is continuing to operationalize its legal strategies and tactics, including filing an injunction to halt the PMMP and a broader suit against Highmark. While exact details must not be disclosed at this time, an official announcement is expected by the middle of next week.
Dr. Schatzberg concluded by saying, “Our doctors must continue to support their patients and likewise their professional association, PCA, in these important initiatives. There is no better way, especially at this time, to show support for patients and our profession than:
1.JOIN PCA IMMEDIATELY- It really is an issue of strength through membership. PCA staff will work with you to make dues payment arrangements that are suitable to your individual circumstances and needs;
2. Financially contribute to PCA’s Legal Fund and PCA’s Political Action Committee.
I urge our members and for that matter, ALL Doctors of Chiropractic to stand up for their profession and contribute generously and as often as possible to both funds. As readers can readily see in this update and others we have posted or sent to you, PCA’s legal strategy is tied to our political strategy and vice versa.
Prospective new members and contributors should continue to regularly visit PCA’s web site, where timely information and useful links to resources will help support patient care, as well as the future of chiropractic and physical medicine. Read more.
Problems Plague Highmark PMMP Program
Chiropractors urge shelving of controversial computer program that determines patient treatments
Harrisburg, PA 9/19/2012 - Pennsylvania’s chiropractors, physical and occupational therapists, and patients continue to experience widespread problems and confusion over Highmark Inc’s controversial Physical Medicine Management Plan (PMMP), a computer software program that determines treatment allowances for patients, rather than their doctors or therapists. Officials from the Pennsylvania Chiropractic Association (PCA), which has been leading the charge against the faulty program since Highmark first announced it in June, today said there are widespread problems with the program and urged state legislators, insurance regulators and Highmark officials themselves to abandon the ill-advised effort.
On a related note, PCA said opposition to the poorly-conceived plan continues to grow, with over 1,800 petition signatures against it and nearly 200 additional persons signing on to an anti-PMMP Facebook page.
“We have been very impressed with the support we’re receiving regarding Highmark’s ill-advised PMMP,” said PCA President Dr. Daniel Schatzberg, of Media, PA. “Over 2,000 patients, doctors, therapists and others have formally noted their opposition to Highmark’s actions, and literally tens of thousands of dollars have been donated to our Legal Fund to help fight its implementation. Highmark probably wishes we would just go away and allow them to do whatever they want, but that is not going to happen.”
Schatzberg said PCA and other physical medicine practitioners across the state continue to receive complaints about the program, which has been ‘soft launched’ for September by Highmark. “Every day we receive information about problems with the program,” noted Schatzberg. “From outright denials for treatments one day, to complete reversals the next, or complete groups being excluded from the program on one day (including Highmark’s own employees), and then included the next. It is very clear to us that Highmark itself is as confused about this program as are the patients and medical professionals affected by it. We again urge Highmark’s senior leadership to seriously consider abandoning this ill-conceived and poorly-administered program.”
Some specific problems identified by PCA members include:
-Online efforts to determine patient eligibility are impossible due to technical errors in Highmark’s software, which flips between “No” and “Yes” without reason. -Highmark representatives who work with doctors are giving contradictory information about PMMP that differs from Highmark’s own program administrative manual. -Patient Choice has been eliminated under Highmark’s PMMP. Once a doctor or therapist begins treating a patient under Highmark’s PMMP, that patient cannot change to a different doctor or therapist. Nor can a patient have two different providers, such as a physical therapist and a chiropractor. Once a patient selects a chiropractor or therapist under PMMP, they are bound to them for at least a year. This is a fundamental violation of basic patient rights.
Schatzberg said that his organization, which represents over 1,000 chiropractors across the state, is resolute in its opposition to the program and will take legal steps to prevent its full implementation. “Our members and patients have spoken loudly and clearly in opposition to this, as is evidenced by their concerns and in the many donations to the legal fund we’ve received in the past two weeks,” said Schatzberg. “We will use whatever other resources may be available to us as well, including urging the PA Insurance Department and the state legislature to help stop the outrageous imposition of Highmark’s PMMP.”
“This is a faulty program designed to increase profits for a non-profit company, at the expense of the patient and the employers who pay for their workers’ insurance coverage. Meanwhile hundreds of thousands of Pennsylvanians insured by Highmark will suffer a lessened quality of life, lowered work productivity, and increased reliance upon drugs or surgery if PMMP is allowed to proceed. All of this while Highmark has secured yet another rate increase from its millions of customers. This is unconscionable, unethical and greedy corporate policy at its worst,” noted Dr. Schatzberg.
Highmark’s Payment Methodology Revealed
Readers are provided this 2008 Highmark document for their reference in order to develop a better understanding of Highmark’s payment methodologies and any relationship to Highmark’s Physical Medicine Management Program (PMMP). Click here to download
Patient Rights Remain at Stake in Highmark Battle
Insurer delays full implementation of controversial program impacting chiropractors, physical and occupational therapists
Harrisburg, PA 8/28/12 – Hundreds of thousands of Highmark customers receiving physical medicine care today received a temporary reprieve from losing their coverage as the large healthcare insurer announced it is stalling its official implementation of the new and controversial Physical Medicine Management Program (PMMP), or Physical Medicine Authorization program, as they more recently rebranded the cost savings effort.
Pennsylvania Chiropractic Association (PCA) President Daniel Schatzberg lauded the efforts of the PA Insurance Commissioner Michael Consedine for his efforts to stop Highmark from implementing the program: “Commissioner Consedine deserves our thanks and appreciation for taking steps to address this looming crisis in healthcare in Pennsylvania. We are well aware that the Commissioner’s intervention in this matter is what gained a brief reprieve for Pennsylvania’s patients, employers and physical medicine professionals. All Highmark customers in Pennsylvania should thank the Insurance Commissioner for his efforts to protect their basic patient rights, while also urging him to shut down the entire program.”
“While it’s not the victory we had hoped for, Highmark’s delay in fully implementing the program proves there is widespread opposition to and Highmark-induced confusion about the program. Be assured that the PCA, the Pennsylvania Physical Therapy Association, the Pennsylvania Occupational Therapy Association and many other groups and consumers in Pennsylvania will continue the fight against this profit-centered and foolhardy Highmark program,” added Schatzberg.
The delay of the program was announced to providers earlier today in a special message issued over Highmark’s communications network with providers. In its statement, the company said:
Consistent with previous communications to our providers and members, the Physical Medicine program will go live September 1, 2012. However, Highmark has decided to institute a “soft implementation” of the program to allow more time for providers to become accustomed to the guidelines and procedures of the program. Many of the providers impacted by this program may not be accustomed to submitting prior auth requests, especially via NaviNet and may need more time to get acclimated. Therefore, while provider offices become familiar with the system, no denials based on medical necessity or appropriateness will be issued for requests with dates of service prior to October 1, 2012. Beginning with dates of service on/after October 1, 2012, determinations will be made regarding the medical necessity and appropriateness of the request . If the request does not meet the criteria (including Highmark Medical Policies), adverse determinations will be issued with all the applicable appeal rights outlined in the notifications. In the interim, providers are expected to still register their members for dates of service in September.
The controversial new PMMP program, to be managed by Virginia-based Healthways, relies upon an unproven and faulty computer software program to make decisions about a patient’s care and treatment, rather than the doctor or therapist who actually examines and talks with the patient. Many patients will be denied treatment by the new program, or severely restricted in what they may be treated or how many times they may be treated.
Healthways itself has a questionable performance record. The company was sued in 2008 by purchasers of Healthways common stock (US District Court- Nashville Division; class action) for among other allegations, a failure to meet savings targets and making knowingly misleading positive public statements about the company’s participation in the Centers for Medicare & Medicaid Services’ (CMS) Phase 1 of its Medicare Health Support pilot project.
“At its heart,” said Dr. Schatzberg, “Highmark’s PMMP is a gross violation of a patient’s right to seek the type of treatment they need, as a computer will now decide what, how and when they may be treated. This computer program removes the healthcare professional’s clinical opinion about a patient’s treatment from the equation, which is an extremely dangerous precedent.”
“We urge Doctors of Chiropractic, physical and occupational therapists, Pennsylvania employers and our many patients to continue putting pressure on Highmark, the PA Insurance Department and Pennsylvania’s state senators and representatives to abandon this ill-advised and problematic program. This is quite clearly a significant public policy and patient safety and protection issue,” said Schatzberg.
State’s Chiropractors Urge Legislators to Help Delay Controversial Highmark Inc. Plan
New computer software program to reduce or eliminate physical medicine services for millions of Highmark customers beginning September 1
Harrisburg, PA (8/28/12) – Pennsylvania’s primary medical care association representing more than a thousand chiropractors has taken its opposition to a controversial new Highmark Inc. plan to the halls of Capital Hill in Harrisburg, urging state legislators to intervene with the State Insurance Commission and halt the planned September 1st implementation of the problem-plagued Physical Medicine Management Program (PMMP), or Physical Medicine Authorization plan, as Highmark has recently changed the name too.
Dr. Daniel Schatzberg, President of the Pennsylvania Chiropractic Association (PCA), today said his organization has sent letters to every senator and house member urging them to act on behalf of hundreds of thousands of physical medicine patients across the Commonwealth who are about to either lose coverage or have it severely restricted by Highmark.
Highmark’s controversial PMMP essentially involves a computer software program making the decisions on whether Highmark insurees may utilize physical medicine services, and if so how many and what type of treatments they may receive. The recommendations of the doctors or therapists who actually examine and speak with the patient will be largely ignored once the program goes into effect, meaning a computer program will be making diagnostic and treatment decisions for patients, rather than their actual provider.
Schatzberg said his Association has been working diligently for months on getting the State Insurance Commission to act on the matter by delaying Highmark’s implementation of the program until many serious operational problems are solved. But to-date the Commission has done nothing. “We are hopeful that pressure on the Commissioner from our elected state representatives will produce better results than we have been able to accomplish,” said Schatzberg, “which has basically ignored us since this Highmark plan first came to light in June.”
“This issue is very important to consumers and medical professionals,” said Schatzberg. “Just last week we started an on-line petition drive that in four days has resulted in more than 400 signatures, and a Facebook Page designated Stop Highmark’s PMMP has generated nearly 100 Likes in just its first few days of operation. Clearly the public and the medical community is very concerned about Highmark’s PMMP. We think our elected leaders should be too!
The below response and attachments have been sent to all members of the PA Senate and House of Representatives, as well as Governor Corbett and Insurance Commissioner Consedine. PCA urges its members to contact the Governor, Insurance Commissioner and respective state senator and representative to urge their support in stopping Highmark’s PMMP.
PCA’s Response to PA General Assembly Members-
August 30, 2012 - On behalf of more than 7,000 small businesses in Pennsylvania that also provide physical medicine services to YOUR constitutuents (both employers and patients), following is the response from the Pennsylvania Chiropractic Association to Highmark’s most recent maneuver to avoid further public scrutiny of their faltering and poorly planned Physical Medicine Management Program (PMMP).
The ENTIRE physical medicine community of Pennsylvania professionals opposes this heavy-handed, clearly self-serving and inappropriate initiative by Highmark. What you may not be aware of is that Highmark intends to impose this program on PEBTF employees and their families on January 1, 2013. All in the perverse interest of Highmark’s profits, rather than YOUR constituents’ well-being. To add a finer point to this email, while Highmark is reducing access to care, they are also requesting significant premium increases, rather than reductions, which will hurt even more Pennsylvania small businesses and employees.
The PCA, as well as the PA Physical Therapy Association (PPTA), PA Occupational Therapy Association (POTA), Chiropractice Fellowship of Pennsylvania (CFoP) and others, urge you to request that PA Insurance Commissioner Michael Consedine immediately stop Highmark’s PMMP until public hearings can be held to address numerous issues inherent to this grossly ill-advised and discriminataory effort to reduce access to care- by computer algorithm, no less- interfere in the doctor-patient relationship and further pad Highmark’s burgeoning ($4.2 BILLION and climbing) reserve fund.
STOP HIGHMARK'S PMMP
Dear Colleague and Fellow Medical Professional,
Your Pennsylvania Chiropractic Association is working diligently to prevent Highmark from implementing its planned Physical Medicine Management Program on September 1. If allowed to proceed, PMMP will have a devastating impact upon chiropractic and physical/occupational therapy practices by removing the provider from the decision-making process in treating our patients, and limiting our patients’ rights to choose the type of treatments they prefer. Instead, Highmark will use a secret and unproven computer software program that makes decisions based upon cost to the insurer, and not what’s best for the patient.
To assist us in our efforts to stop Highmark, PCA is currently urging PA State Insurance Commissioner Michael Consedine to use the power of the Insurance Commission to prevent PMMP’s implementation. To show the Commissioner that our position has widespread support, we are urging both providers and patients to sign petitions opposing PMMP. Attached you will find links to two separate online petitions, one for providers and other medical professionals, and one for consumers/patients.
A hard copy of the Patient Petition is also attached for in-office use if you prefer that format. By securing many thousands of signatures on these petitions we hope to provide tangible proof of the seriousness of this issue to Commissioner Consedine, and show the widespread support the state has from our patients and our industry for taking protective action against Highmark’s questionable business practices. We have also established a Facebook page on the issue, the link to which is provided below.
Thank you for your support and help! The future viability of each of our practices, and more importantly our patients’ fundamental rights to choose physical medicine services, are very much at stake with this issue.
Dr. Daniel Schatzberg, President
Pennsylvania Chiropractic Association
Physical Therapy Coverage on Sept. 1;
Patient Rights Being Violated
New computer program will determine eligibility and treatments for chiropractic and physical therapy services – not doctors or therapists
Harrisburg, PA 8/20/12 – Millions of Americans insured by Highmark Inc. are about to have some of their medical treatments decided by a computer program, rather than their doctor or therapist, according to a professional healthcare association in Pennsylvania. The Pennsylvania Chiropractic Association (PCA) today warned Highmark customers that the company is changing coverage for physical medicine services, which include chiropractic, physical and occupational therapy treatments starting September 1, 2012. Healthcare consumers and professionals are urging the state insurance department to prevent the controversial program from being implemented.
Highmark’s usage of the new software program, known as the Physical Medicine Management Program (PMMP), is at the heart of the devastating changes being made by the insurer. The computer program will begin making the treatment decisions for patients, rather than the doctor or therapist who actually examined the patient and made the diagnosis.
“This is a chilling snapshot of the future of healthcare in America, and one of the most egregious violations of a patient’s right to choice as we’ve seen,” said Dr. Daniel Schatzberg, President of the PCA, which represents more than a thousand chiropractors in Pennsylvania. “Doctors and therapists who are actually seeing the patient will no longer have control over that patient’s treatment. Instead, a computer algorithm will decide if a patient is even eligible for treatment, and if they are, how and when they will be treated. ‘1984’ has truly come to healthcare, thanks to the questionable business practices of Highmark.”
Highmark’s use of the unproven and troubling evaluation plan was made without consumer input or regulatory or legislative oversight, even though a test program being used in Massachusetts has failed miserably. Pennsylvania state legislators and the state insurance commissioner have been completely silent on the issue and no official efforts have been made to stop the company from implementing the program.
“On September 1st, Highmark customers who rely upon chiropractic or physical or occupational therapy treatments will suddenly find their cases being analyzed by a computer software program,” said Dr. David Novatnak, a leading official with PCA who has headed the group’s opposition to the Highmark program. “Millions of Americans are about to lose or have their access to these important types of treatments severely restricted. This will have a devastating impact on both their quality of life and economic productivity.”
“Ultimately, millions of people will be forced to live with greater pain and discomfort, or be forced into more expensive drug or surgical solutions for their maladies, which not coincidentally generate far higher profits for Highmark. So too will thousands of chiropractors and physical and occupational therapists be forced from their careers because of Highmark’s new PMMP, just so the company can add to its existing $3.7 billion in cash reserves,” noted Novatnak.
Schatzberg and Novatnak urged Highmark customers in Pennsylvania who depend upon chiropractic or physical therapy services to immediately contact their state legislators and the office of state insurance commissioner Michael Consedine to express their opposition to the Highmark PMMP plan.
Contact the Insurance Commissioner at:
The Honorable Michael Consedine, Commissioner
PA Department of Insurance
1326 Strawberry Square
Harrisburg, PA 17120
Tele: (717) 783-2005
ARE YOU FRUSTRATED WITH HIGHMARK’S WEBINARS AND GENERAL LACK OF USEFUL INFORMATION ON PMMP? IRRITATED THAT THE SEPTEMBER 1 DEADLINE IS LOOMING, YET YOU DON’T HAVE ADEQUATE INFORMATION ON THE PMMP TO MAKE AN INFORMED DECISION ABOUT THE PROGRAM?
One member recently emailed PCA, with the following comments about Highmark’s PMMP
While we all agree with this situation, how about some useful info on how to deal with it? What is the best way to fill out these forms? Are the forms pre-populated with doctor and patient information so we can fill them out with a little more ease? Also, I have found that many members don't know that Medicare has changed their diagnosis parameters for the number of treatments as well as limited acceptable diagnosis. Again, when Medicare makes a change there should be a giant red flag from you with helpful info for the average doctor. Just a little feedback from one of your members in the trenches of healthcare.
PCA is in no way supporting Highmark’s PMMP and is doing everything within its resources to stop the program.
As reported by many PCA members, if Highmark’s dysfunctional PMMP webinars and evidently uninformed provider reps cannot give doctors consistently accurate information on all of the facets of the program, how could PCA possibly do any better with any level of authority or accuracy, especially when Highmark refuses to give up either their promised FAQs or meaningful details of their program that our doctors need to know?
EVERY doctor must take personal responsibility for deciding their future with the PMMP. This means that each doctor should carefully review the PMMP contract, and with the advice from her/ his legal counsel, coding consultant and financial advisor, make an informed individual decision as to whether to participate or not participate in Highmark’s PMMP. Highmark should provide detailed, accurate and complete information to chiropractors, so chiropractors can have full disclosure before making decisions regarding the PMMP program If doctors are not getting what they need from their provider reps, they should contact the key senior Highmark decision-makers and voice their opposition to and complaints about Highmark providing inadequate decision-making information to providers.
Please Google Highmark’s senior staff for their contact information or simply direct your concerns and questions to:
Dr. William Winkenwerder, MD, MBA
President & CEO
120 Fifth Avenue, Suite 3111
Pittsburgh, PA 15222
Beverly Evans, Assistant
Dr. Donald Fischer, MD, MBA
Senior Vice President &
Chief Medical Officer
120 Fifth Avenue, Suite 3019
Pittsburgh, PA 15222
Bonnie Davis, Assistant
Dr. Virginia Calega, MD, MBA
Vice President, Medical
Management & Policy
120 Fifth Avenue, Suite P4105
Pittsburgh, PA 15222-3099
Mr. Matthew Vogel, CPA, MBA
Vice President, Provider
Contracting & Relations
1800 Center Street
P.O. Box 890089
Camp Hill, PA 17089-0089
Ms. Michelle Sherman
Director, Professional Relations
1800 Center Street
P.O. Box 890089
Camp Hill, PA 17089-0089
Ms. Melissa Stem
Director of Provider Relations
120 Fifth Avenue
Pittsburgh, PA 15222
Holly Van Wagenen, Assistant
Highmark Snubs Patients and Doctors, Favors Computer to
August 6, 2012 - Health care has always been very personal, uniquely between the patient and health care provider, and for the most part, “'hands on.” All of that is about to come to an end, if one Pennsylvania health insurance company has its way. In this case, however, there's a BIG twist: a computer will decide what is “medically necessary,” rather than patients and their doctors. Read More!
Participate in Your Survival:
PCA’s Case Against Highmark’s Physical Medicine Management Program
(This article was collaboratively written by PCA’s Highmark
PMMP Working Group)
CAUTION: PCA FULLY SUPPORTS A STRICT ANTITRUST POLICY THAT PROHIBITS BOYCOTTS, PRICEFIXING, INFORMATION EXCHANGES AND “REFUSALS TO DEAL.” ALL PCA MEMBERS AND NON-MEMBERS SHOULD REVIEW THE POLICY BEFORE TAKING ANY ACTION THAT COULD VIOLATE FEDERAL AND STATE ANTI-TRUST LAWS. IF MEMBERS HAVE ANY QUESTIONS IN THIS REGARD, PLEASE DIRECT THOSE QUESTIONS TO PCA AND PCA WILL DIRECT INQUIRIES TO PCA’S GENERAL COUNSEL.
In addition to PCA’s list of issues and concerns (see related link to materials below), the Pennsylvania Physical Therapy Association has raised significant concerns regarding Highmark’s PMMP via a mid-July letter from PPTA President Ivan Mulligan to Highmark’s Dr. Virginia Calega, Vice President of Medical Management and Policy.
Despite two lengthy meetings between PCA’s Highmark Working Group and Highmark’s senior VPs in which numerous serious concerns were raised about the integrity and readiness of Highmark’s Physical Medicine Management Program (PMMP), the massive health insurer evidently remains committed to starting the flawed program on September 1, 2012. Highmark’s cavalier actions are being done in knowing disregard of the numerous complaints reported to PCA from doctors who have tried, with mostly poor results, to participate in Highmark’s informational webinars and/or asked numerous questions that were inconsistently addressed by the insurer in either webinars or via their provider representatives.
Even in the face of these serious missteps and failures in technology, on January 1, 2013, Highmark also plans to impose its PMMP program on one of the state's largest employers and purchasers of health insurance: the Pennsylvania Employee Benefits Trust Fund, which serves the Commonwealth of Pennsylvania's tens of thousands of employees.
The PCA remains opposed to Highmark’s fatally-flawed PMMP, AND remains open to finding a workable solution that addresses all parties’ concerns regarding patients’ accessibility to and proper management of physical medicine services. Simply put, Highmark’s PMMP is very bad medicine for patients and health care professionals.
For a comprehensive summary of this issue and PCA’s intervention with Highmark, click here!
PA Physical Therapists Have “Great Concerns” About Highmark’s PMMP
On July 12, 2012, Pennsylvania Physical Therapy Association President Ivan Mulligan, PT, DSc, SCS, ATC, CSCS sent a letter to Highmark’s Virginia C. Calega, M.D., M.B.A., Vice President of Medical Management & Policy, expressing the association’s “great concern” with Highmark’s Physical Medicine Management Program, which starts September 1, 2012. Of particular interest to Doctors of Chiropractic is the fact that PPTA has been attempting to work with Highmark on their physical medicine program since 2005, with limited, if any, meaningful responses from Highmark.
PPTA President Mulligan’s letter can be read in its entirety by clicking on the below link. PCA is working closely with PPTA and other professionals to stop implementation of Highmark’s PMMP. Read complete letter!
PCA’s OPPOSITION TO HIGHMARK'S PMMP TAKES SHAPE
PCA’s open opposition to the June 14 Highmark “special bulletin” announcing its Physical Medicine Management Program (PMMP) has now moved into its next phase, according to newly-elected PCA President Dan Schatzberg, D.C.
Schatzberg said, “Beyond our June 20 announcement opposing the PMMP, PCA has quickly moved in the past week to take first steps to stop this program. Our first phase of activity has been corresponding with both Highmark and other key stakeholders. PCA remains committed to an open and transparent process that will address the numerous ambiguities in the PMMP. To date, program details have been sorely lacking on the behalf of Highmark. Through our own analysis of the initial information we’ve received on the PMMP, including contacts with Highmark’s provider representatives, there are many more questions than there are answers, thus, our letter to Highmark’s Virginia Calega, M.D., Vice President of Medical Management & Policy, seeking more clarity on its Physical Medicine Management Program.”
Dr. Schatzberg indicated that as more information becomes available, additional correspondence and updates on Highmark’s PMMP will be first posted on PCA’s web site. Last week, acting under the direction of the PCA Board of Directors, PCA’s Executive Committee retained well-respected health law attorney Charles I. Artz, Esq. to represent the interests of PCA members. Artz and PCA General Counsel Jason B. Martin, Esq. are working directly with Dr. Schatzberg, Dr. Eric Osterberg, PCA’s 1st Vice President, nationally-recognized coding expert Dr. David Novatnak and Drs. Bill Aukerman and Brian Tokach, members of PCA’s Executive Committee.
Dr. Schatzberg also noted that Highmark’s PMMP has drawn the “serious attention” of the American Chiropractic Association, which is working with PCA on the PMMP initiative. During PCA’s June 22-24 Annual Convention, extensive conversations and meetings were held with ACA President Keith Overland, D.C., on the Highmark issue and other matters. Dr. Overland repeatedly expressed ACA’s support of PCA’s efforts to stop the PMMP from being implemented.
To read Attorney Martin’s letter to Highmark, click here.
PCA STRONGLY OPPOSES NEW HIGHMARK PROGRAM
Highmark’s Physical Medicine Management Program, announced to Pennsylvania’s Chiropractors and others, via a June 14 special bulletin, was “special” indeed. Chiropractors need to know that PCA is gearing up for an intensive fight to stop this program.
PCA’s fight against Highmark, on behalf of ALL Chiropractors in Pennsylvania, will require a unified and aggressive approach to dealing with one of the USA’s largest and wealthiest health insurance companies. Our approach and success will be closely tied to how many Chiropractors step-up to join PCA. Each doctor must write letters, make phone calls and speak up in opposition to this cost-containment, reserve-building program that benefits Highmark’s bottom line and shareholders’ interests, rather than the well-being of patients and the patient-provider relationship.
What PCA is seeking is simple: ceasing any further development of this program, and an immediate legislative inquiry into both the program itself and Highmark’s reserve fund, now estimated at $3.7 Billion and growing every minute.
There are four (4) important links for you to download:
3. Sample letter templates (MS Word doc) that ALL doctors and their patients should personalize and mail to Governor Corbett, Insurance Commissioner Consedine, and state senators and state representatives Click here!
BE COMMITTED. BE INVOLVED.
Respectfully Yours in Chiropractic,
YOUR PCA Board of Directors