Shirlee Zerkel and Greg Nickell: More discussion

From Shirlee Zerkel, December 15, 2006

Subject: Fwd: Questions about preventive services in Basic Plan for 2007
This is the answer I received from Mr. Nickell last night. Our suggestions are always nice in the discussion stage but apparently to staff not workable. I do not buy the excuse of the doctor's billing methods being the reason that our suggestion would not work. Doctors are ordered by the insurance companies as to how to bill or code items -- the example is right in Mr. Nickell's email where he speaks of the doctor having to use the correct code for it to be paid as preventive.

Shirlee Zerkel
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Dear Ms. Zerkel:

I appreciate your suggestion and understand it makes sense at the discussion level. However, when it comes to processing claims we must remember that all Aetna and Medical Mutual have to determine how a claim adjudicates is what is submitted on the claim. My experience from the past (I was a senior executive responsible for health claims operations at a Third Party Administrator (TPA) for 14 years) suggests caution when looking at asking physicians to alter their billing practices. When a request is outside the standard coding guidelines the results most likely will be very inconsistent leading to frustration from all parties.

Regarding your second question, the 100% preventive service coverage would extend to the related charges billed for facility and anesthetist services providing the claims are submitted by a network provider with a preventive diagnosis and/or procedure code.

Thank you for letting me know your concerns.

Sincerely,

Gregory R Nickell

Director, Health Care Services

nickellg@strsoh.org