Arizona Physician Winter 2022

A PUBLICATION OF THE MARICOPA COUNTY MEDICAL SOCIETY

Building on a Medical Family Legacy

Orthopedic spine surgeon Chris Yeung, MD, talks about overcoming obstacles set by insurance companies

Physicians across Arizona share their thoughts on how insurance impacts medicine

Editor-In-Chief

John McElligott, MPH, CPH

Managing Editor Edward Araujo

Associate Editor Nayeli L. Guzman

Creative Design

Randi Karabin, KarabinCreative.com

Cover & Featured Articles

Photography Ben Scolaro, scolarodesign.com

Advertising ads@arizonaphysician.com

Maricopa County Medical Society Board Members

President Ricardo Correa, MD, EdD, FACP, FACE

President-Elect

Zaid Fadul, MD, FS, FAAFP

Treasurer Vishal Verma, MD, MBA

Secretary Jane Lyons, MD

Directors

Kishlay Anand, MD, MS

Jay Arora, MD, MBA

David Carfagno, DO, CAQSM

Christopher DeNapoles, MD

Ann Cheri Foxx-Leach, MD, D.ABA

Anchit Mehrotra, MD

Ruchir Patel, MD, FACP

Rahul S. Rishi, DO, FAAAAI, FACAAI

Karyne Vinales, MD

Resident & Fellow Director Emma Schnuckle, MD

Medical Student Director

Anirudh Singh, OMS-IV

Chris Yeung, MD, orthopedic spine surgeon at Desert Institute for Spine Care, shares how he is building on a family medical legacy.

Valle del Sol’s Dr. Suganya Karuppana discusses the impact the Inflation Reduction Act will have on healthcare.

Drs. Sujatha Gunnala and Vinay Gunnala of Southwest Fertility Center discuss how insurance affects fertility coverage.

The Complicated World of Insurance

Before I start my last column, I want to thank everyone who serves on committees and the Board of Directors of our county medical society. What we achieved in 2022 was made possible because of your time and dedication to organized medicine.

Our DEI committee focused its activities on educating the workforce and outreach to the community. We collaborated with other organizations to help decrease disparities in access to health care. Our policy committee saw its most activity in the last 10 years. We analyzed proposals in the state legislature, took positions on bills, produced statements on some issues, and built relationships with legislators. Our CME committee offered more than 10 CME activities. We started doing Virtual Townhall meetings to hear from our members. Our partnership committee created a pathway for more member benefits. Despite being a difficult year for medical societies, our amazing board and staff helped to advance our organization.

In addition, I want to give a special thanks to all our staff (John, Alex, Edward, Sewit, Nayeli) for their hard work.

COVERING AMERICA

The United States has no single nationwide system of health insurance. Health insurance is purchased in the private marketplace or provided by the government to certain groups. Private health insurance can be purchased from various for-profit commercial insurance companies or from non-profit insurers. About 84% of the population is covered by either public (26%) or private (70%) health insurance.

The two major types of public health insurance include Medicare and Medicaid. Medicare is the largest health insurer, covering about 13% of the population.

Many uninsured people receive health care services through public clinics and hospitals, state and local health programs, or private providers that finance the care through charity and by shifting costs to other payers. Nevertheless, the lack of health insurance can cause uninsured households to face considerable financial hardship and insecurity.

THE AFFORDABLE CARE ACT

The Patient Protection and Affordable Care Act (ACA) plans have some essential health benefits and many offer subsidies for Americans who cannot afford the full premiums.

The ACA allows parents to add children up to the age of 26 to their policies, in a bid to have young, healthy people paying premiums. It also allows poorer people to get treatment for chronic illnesses instead of using the emergency room.

PRIVATE HEALTH INSURANCE

Private health insurance currently covers a little more than 60% of the U.S. population.

Private health insurance includes employer-sponsored plans, which cover about half of the American population. Another 6% of Americans purchase private coverage outside of the workplace in the individual/family health insurance market, both on and off-exchange.

Most cases of private health insurance are subsidized by the government. Employer-sponsored health insurance is subsidized via the tax code, as it’s typically offered as a pre-tax benefit for employees.

As you know, it is not easy to navigate our complex healthcare system. In this issue, you will see amazing articles that will help you to understand a little bit more about health insurance and its impacts on physicians.

Ricardo Correa, MD, EdD, FACP, FACE MCMS Board President

Dr. Ricardo Correa is an endocrinologist at the Phoenix VA Medical Center. He is also the Endocrinology, Diabetes and Metabolism Fellowship Director, Director of Diversity GME, and Chair of the GME Diversity Subcommittee for the University of Arizona College of Medicine Phoenix. Dr. Correa is the Health Equity Fellowship Director for the Creighton School of Medicine and Medical Director of the Phoenix Allies for Community Health (PACH) Clinic. He is a Major in the U.S. Army Reserve.

Interested in getting involved with MCMS? Reach me

Respectfully,

Providing quality care for 100 years

For the last century, the Good Samaritan Society has been committed to providing an unprecedented level of quality service to ensure your patients are safe and cared for.

Our expansive footprint ensures we have the expertise to provide them with a smooth transition through various levels of care.

“We’ve been doing this for 100 years. We specialize in it,” says the Good Samaritan Society’s chief medical officer, Gregory Johnson, MD. “We provide support that meets people where they are.”

And this support starts immediately after someone is discharged from the hospital.

“We work with our hospital and physician partners. That’s a special level of collaboration and integration,” Dr. Johnson says.

The impact of exceptional senior care

Delivering the best care in a resident-centered environment has always been our focus. We believe that relationships, collaboration and human connection are essential to what we do.

Using an integrated approach, we’re improving quality of life and well-being while continually developing better standards of care across our communities. Services vary by location but may include:

• Assisted living – Convenient, maintenance-free living with services, amenities and security features to help residents live vibrantly.

• Home-based services – Customized, in-home medical or non-medical care within the comfort of a person’s home with extra support for meals, medications and more.

• Long-term care – 24-hour care and services for those who need the assistance of licensed nursing or rehabilitative staff.

• Rehab therapy – Quality inpatient or outpatient services using physical, occupational and speech therapies to enhance recovery after a hospitalization, illness or injury.

When you choose the Good Samaritan Society, your patient will be cared for by dedicated experts there to promote their well-being.

Partner with the right choice

Whether your patient needs 24-hour care, rehabilitation therapy or care at home, referrals to the Good Samaritan Society are easy and convenient:

• Call your local Good Samaritan Society location

• Call (855) 446-1862 to speak to a specialist about services

• Visit our Health Care Partners page at good-sam.com to use our simple online referral form

We partner with you to provide the best outcomes for your patient – supporting them physically, emotionally and spiritually through the health care journey.

Whatever level of care they need when leaving the hospital, the Society is ready to help restore their well-being.

If you have questions about referring patients or want to learn more about our services, please call (855) 446-1862 or visit our Health Care Partners page at good-sam.com.

FROM

THE EDITOR-IN-CHIEF

The late Senator John McCain was right. Americans generally agree on wanting an opportunity to earn a living, get medical help when they’re sick, and educate their children so the next generation is in a better spot than the current one. How that happens and who pays is a different story. Our current system in the U.S. has a mix of public and private health insurance. We provide subsidized care for those who cannot afford paying full price and we offer socialized medicine to veterans. Some physicians work to improve care within the current system, which is widely criticized as being inefficient and too costly. Others want the U.S. to provide universal coverage.

IMPACT OF PRIVATE INSURANCE

According to a 2021 report titled, “Surveys of Trust in the U.S. Health Care System,” from NORC at the University of Chicago, 19% of 600 surveyed physicians and 33% of 2,069 members of the general public trust health insurance companies. By comparison, higher percentages trusted hospitals (60% of physicians and 72% of the public), government agencies (78% and 56%), and pharmaceutical companies (47% and 34%).

In our sample of physicians in Arizona, only 12% say their interactions with insurance carriers are generally positive. Nearly all respondents wrote about inefficiency and complexity, increasingly low reimbursements for services, additional staff required to manage pre-authorization or denial of payments, and frustration in communicating with insurance companies.

Dr. Vinay Gunnala of Southwest Fertility Center sees the value carriers provide to patients in making some medical treatment more affordable. He also sees the headaches on clinical and non-clinical staff, hurdles to jump through for authorization of services, and interference with medical care he provides to patients. Getting reimbursed at the appropriate rates is a huge struggle.

MPH and DMD candidate Colar Kuhns examines the issue, writing that physicians believe “insurance has lowered patient confidence in the care providers offer.” Some doctors are so fed up they would not recommend a career in medicine.

Dr. Claudia Gaefke of Allergy Asthma Clinic wants a peer-to-peer review with a physician of the same specialty when carriers challenge her decisions.

SPINE SURGEON’S VIEW

Dr. Christopher A. Yeung, orthopedic spine surgeon at Desert Institute for Spine Care, shares his take on insurance and the mix of payments he and his colleagues at DISC receive from commercial insurance, Medicare, cash, and worker’s compensation. “Unfortunately, health care costs have skyrocketed, and insurance companies are trying to control costs, and a big way they do it is to just reflexively deny care,” says Dr. Yeung.

His practice feels the burden of the increasing administrative requirements. Managing Editor Edward Araujo writes, “The consequences of the stress and red tape lead to strained doctor-patient relationships because patients are made to wait while in pain, with some told their treatment or procedure will be denied. Those patients place the blame on the physician.”

VALUABLE ARTICLES

In Legal Corner, lawyer Miranda Preston of Milligan Lawless shares helpful information when negotiating a contract with commercial health insurance plans.

Dr. Suganya Karuppana, Chief Medical Officer of Valle del Sol, writes about the potential impact of provisions in the Inflation Reduction Act to lower prescription drug costs for seniors.

Contact us at info@arizonaphysician.com with any comments or suggestions.

Enjoy the magazine.

By John E. McElligott, MPH, CPH

Not an MCMS member? Visit mcmsonline.com/join or call us at (602) 252-2015.

“AMERICANS WANT JOBS. THEY WANT AFFORDABLE HEALTH INSURANCE. THEY WANT AN EDUCATION.” —John McCain

WHAT IS THE PARTNER PROGRAM

Maricopa County Medical Society’s Partner Program is designed to introduce select companies to our members. MCMS strives to facilitate physician growth in all areas of their life and practice. As we work to support our members, we think there are excellent opportunities to work closely with business partners that can facilitate that growth.

Learn more at mcmsonline.com/ partner-program

PREFERRED PARTNER

WHY GLIDIAN

MCMS repeatedly hears from physicians that prior authorization is a hassle. You want to reduce the administrative burden and focus on providing medical care. Glidian simplifies prior authorizations by incorporating insurance-specific requirements from medical policies and automatically updates as policies change. Streamline your workflow. Prevent denials. Get decisions sooner.

How It Works

STEP 1 | Submit electronically through Glidian

Submit all your authorizations through a single interface with no need to fax or call health plans. The submission process incorporates insurance specific forms and criteria to prevent delays.

STEP 2 | Glidian securely communicates with insurance

Data is encrypted during transmission and handled in a HIPAA compliant manner. Send and receive data from insurance companies directly through the platform.

STEP 3 | Receive real-time notifications when cases are approved No need to constantly check the status of a case by calling health plans or checking portals. Notifications are pushed automatically when the status of a case changes.

Learn More Find out how your team can simply prior authorizations with Glidian. Visitmcmsonline.com/preferred-partners and request a demo.

NOTES FROM THE FIELD

7 Films to Watch with Family During the Holiday

The holidays are upon us. So, while you bake those cookies or put up your Christmas tree, you may want to enjoy a few recent popular movies.

LOVE HARD (2021) | Looking for love on a dating app? A hopeless romantic but perpetually single LA journalist, Natalie (Nina Dobrev) finally finds love when she swipes right on a dreamy guy from the East Coast, Tag (Darren Barnet). In an attempt to surprise her crush for the holidays, she jumps on a flight, only to discover she has been catfished by Tag’s childhood friend, Josh (Jimmy O. Yang). This lighthearted romantic comedy portrays the dating scene of the 21st century.

THE HOLIDAY (2006) | This rom com is a classic, and although the plot is quite predictable, it is still the perfect movie to watch during the holidays. An American woman and a European woman swap homes to escape heartbreak, only to find love again. And this time is for real.

ENOLA HOLMES (2020) | If you enjoy mystery films and are already a fan of Sherlock Holmes, you should learn about his fictional sister and her thrilling adventures. This story focuses on the misinterpreted female power that has been ignored for centuries. The sequel was released on Netflix in 2022.

MARCEL THE SHELL WITH SHOES ON (2022) | This animated comedy about a tiny shell that wears shoes will teach you some collectivistic-valuable lessons. As we transition to a virtual environment, we leave a sense of community behind. Marcel and his grandmother Connie have been surviving alone for the past two years at an Airbnb-home, until the opportunity to be reunited with their community is presented again.

COCO (2017) | You don’t have to be of Mexican heritage to shed some tears on this one. Despite his family’s opinions about being a musician, Miguel is

accidentally transported to the Land of the Dead. He’s on a mission to seek the help of his deceased “great-great-grandfather” who was once a musician. This film honors Mexican cultural traditions and shows us why they’re important.

DUNE (2021) | This remake of the 1984 film should be on your watch list if you haven’t watched it yet. There are several themes that Dune explores, including scarcity, diversity, gender, and religion. With characters representing a more diverse range of backgrounds, this adaptation closely follows the themes of the Dune book series by Frank Herbert (1965).

SOUL (2020) | This Pixar-animated film portrays a deep message of existentialism, and it is also the first Pixar film to feature a Black lead character. The story follows a pianist, Joe Gardener, that suffers an accident and gets trapped in a stage before the afterlife. He’s on a mission to get back to Earth.

5 Winter Foods to Avoid

The winter holiday season is a great time to bring family and food together. Yet, it’s important to remain healthy during the winter months by avoiding (or shall we say, limiting oneself) of the following:

DAIRY | Dairy products are mucus-generating in nature — a feature which may make you prone to wheezing and other infections. Therefore, try to limit intake of cold dairy products such as milk, shakes and smoothies.

MEATS | Heavy foods such as meats are not advised to be taken in the winter season. Experts say that it takes the body longer to digest these, thus making us lethargic at a time when physical activity is already low.

PROCESSED FOODS | Minimizing processed foods is also advisable in the cold weather as they may give rise to allergies in some people.

CAFFEINATED DRINKS | Caffeine can constrict blood vessels and lead to higher blood pressure in lower temperatures. Also, being that caffeine is a stimulant, it can also increase heart rate.

SWEETS | Sugar increases inflammation and associated pain also reduces immunity making you prone to respiratory disorders and depression.

Challenges with Insurance in Private Medical Practice

Medical practice has been changing rapidly over the last decade. Some of the most notable issues facing physicians in private practice include rising administrative burdens, lack of negotiating leverage with insurance carriers, high IT costs, and difficulty in physician recruitment. The COVID-19 pandemic has amplified these challenges among physicians who have recently completed residency or fellowship training and enter private practices where the pressure of managing finances in addition to gaining more clinical proficiency are equally felt. Experienced physicians are also aware of low and falling reimbursement rates, which has manifested in fewer physicians opting to remain in private practice.

The major private medical insurance carriers offering individual and family health coverage in Arizona include, at least, Arizona Complete Health, Banner Health/Aetna, Bright Health, Blue Cross Blue Shield of Arizona, Compass Rose Health Plan, Cigna, Health Net

Federal Services, Medica, Oscar Health Plan, Humana, and United HealthCare. As of 2019, roughly eleven percent of Arizona’s population did not have medical insurance, forty-five percent reported employer sponsored medical coverage, and twenty-seven percent had either Medicaid, Medicare, or a combination of the two. Multiple polls have been conducted to determine physician’s views of insurance carriers. One poll of over six hundred physicians responded with concerns that insurance companies are increasing the cost of health care, interfering with their professional judgement by guiding treatment plans, and enforcing policies that compromise patient health. Additionally, roughly forty-five percent of polled physicians believe insurance has lowered patient confidence in the care providers offer and surprisingly nearly sixty-seven percent of physicians would not recommend a career in medicine. As medical practices largely partner with private insurance carriers, understanding the basis of the provider-carrier relationship provides insight for strategies to maximize a practice’s profitability while reducing provider frustration.

CONSOLIDATION AND TIERING

The trend of medical practice consolidation in the face of insurance carrier consolidation is an issue that causes many of the financial challenges physicians face in private practice. Physicians contractually partnering with other physicians into a single taxable entity has been defined as horizontal consolidation, whereas hospitals or hospital systems acquiring a physician’s practice is known as vertical consolidation. Both horizontal and vertical consolidation have been shown to increase physician prices, regardless of the concentration of physicians within a state’s county. However, when insurance carriers consolidate, physician prices lower as insurance premiums increase, which can be problematic for physicians in larger Arizona cities such as Phoenix, Tucson, Mesa, Chandler, or Glendale. A health insurance market that has limited insurance carrier competition with a large patient pool gives carriers leverage to restrict physician prices, especially when consolidated hospital systems compete against smaller practices for the market share of patients. Inherently, private equity has capitalized on vertical consolidation, increasing hospital system revenue through increased patient prices. Additional challenges with commercial insurance are inherent to the contract between a provider and a carrier.

When a provider joins a carrier’s network, the contractual agreement exchanges access to the carrier’s patients for acceptance of the carrier’s prices. Large corporations such as Walgreens or Nestlé that have significant facilities in cities such as Flagstaff offer insurance plans to their employees that maximize coverage or the quality of care while minimizing the cost of medical care to both the employer and employee. Cost of care can be determined objectively. Employees or corporations can look at the list of prices for various medical procedures offered by an insurance carrier for in-network medical providers and determine if it suits their needs. Quality of care on the other hand is far more subjective and may be more detrimental to a practice’s revenue potential. Insurance carriers take in-network providers

and create a tier system. Tiering providers is based on the evaluation of both the cost and quality of a practice’s medical care. Quality of care can be determined by member experience, how well providers manage member healthcare, and how well the plan is run. If you ever received a bad Yelp review it is understood that depending on the complaint and resolution, the review can either be dismissed by potential patients or can deter a patient(s) from seeking care at a practice. While medical providers that enter an insurance carrier’s network have access to a larger patient pool, the practices are never completely shielded from the effects of negative reviews because the reviews may determine a practice’s standing within a carrier’s tier system. Isolated, sporadic patient complaints are inevitable for a medical practice, but accruing enough complaints that an insurance carrier drops a practice into a “less preferred” status directly impacts future earning potential of the practice and may limit the carrier’s recommendation of services patients should receive from a practice. Once a carrier labels a practice with a less preferred status, it appears that there is not much a practice can do to recover from dropping in the tier system. Thus, avoiding patient dissatisfaction is indirectly incentivized among carriers.

MITIGATE CHALLENGES

Research was conducted by the American Medical Association on strategies to mitigate the challenges providers face with private insurance. One recommendation for growing practices was building an administrative or business management staff, which enabled physicians to focus on clinical care. While a fee-for-service practice may receive higher procedure reimbursement rates, patients largely prefer providers that participate with commercial insurance carriers. According to the interviewed providers, practices that provide high quality care are those that are the most accessible, seek innovation through advanced technology namely in electronic health records, patient portals, and payment systems and “go the extra mile” in actively communicating with a patient. While providers have limited leverage in determining fee schedules with participating insurance carriers, developing relationshipbased care maximizes a practice’s revenue potential. ■

By Colar Kuhns, BS DMD-MPH Candidate

AT Still University

sa202293@atsu.edu

Inflation A Ray of Hope after the Reduction Act

Federal legislation lowers costs for prescription drugs and health insurance

As physicians, we are taught to do no harm. Healthcare providers go to school for years to learn pathophysiology clinical guidelines to help lead patients on a path to wellness. However, soon after we begin to practice, we are faced with a brutal truth: we can often see that path to wellness, but the path is blocked by social determinants of health, barriers to accessing care, and costs of treatment, such as medication. As a result of these barriers, patients develop a distrust of their providers and the healthcare system, while healthcare providers experience burnout and moral injury.

If physicians make a recommendation that we know patients can’t access or can’t afford, we may not be doing harm, but we certainly aren’t doing good either. As patients return to us month after month, year after year, with no end in sight, both healthcare providers and patients remain frustrated, depressed, and hopeless.

Fortunately, help is on the way for providers like me and so many across the nation. President Biden signed the Inflation Reduction Act which lowers health care costs for the American people. Along with fighting inflation and making key investments in climate and energy, the bill will finally rein in prescription drug costs for millions of seniors and continue to make health insurance more affordable and accessible. This is a once-in-a-generation historic piece of legislation, and it infuses us all with a muchneeded ray of hope.

We now have hope because the Inflation Reduction Act will lower health care premiums by extending Affordable Care Act (ACA) Advanced Premium Tax Credits (APTC) for three years, helping level the playing field for working families and deliver affordable care to Americans from all walks of life, including older adults, people with disabilities, people in rural communities, and people of color. The APTC allows Americans who get insurance coverage through the Health Insurance Marketplace® to use a tax credit to lower insurance premium based on estimated income for the year. Extending these tax credits is among the most efficient and direct ways to lower cost of living and deliver long-overdue relief to families, while ensuring they can continue to access the care they need.

WHAT COMES NEXT

Medication will become more affordable for seniors. Decades in the making, the Inflation Reduction Act finally gives Medicare the power to negotiate lower drug prices. This alone will drive down the prices of some of the most popular and expensive drugs for seniors on Medicare. Medicare beneficiaries will have more reasonable caps on out-of-pocket spending on medications, and my personal favorite, the Medicare $35 copay for insulin. This will make a world of a difference for the more than 3.2 million insulin users on Medicare Part D. Polling shows over 80 percent of Americans support giving Medicare the power to negotiate, making it among the most popular provisions in the entire bill. By 2030, more than 80 drugs will be eligible for Medicare price negotiation.

All of this will allow healthcare providers to confidently provide the treatment and care our patients actually need because these barriers will no longer stand in the way. Though much of this legislation only applies to patient with Medicare, there is hope that it will start the precedent for other private insurance plans and Medicaid to then follow with regard to helping medication be more affordable for patients and as well as improve access to care.

As a Family Physician who has been seeing patients for almost 20 years, I now have a ray of hope that soon, my patients will be able to seek out the care and treatment they need without worrying having to choose between their health and putting food on the table or keeping the lights on. I now have a ray of hope that I will be able to spend my time listening, assessing, diagnosing, educating, and guiding my patients rather than filling out prior authorization forms, patient assistance forms, and other piles of denial paperwork in order to advocate for needed treatment.

This legislation gives us hope that providers can guide patients back on that path to wellness by providing them with chronic and preventative care. Providers can develop deeper, more meaningful relationships with patients, leading them to regain trust that their provider and the healthcare system will allow them to access necessary treatment.

So, thank you to our members of Congress and the dedicated advocates for working tirelessly to pass the Inflation Reduction Act. This historic legislation is a huge step forward and it has restored a sense of hope that we can look ahead to a healthier community. ■

By Suganya Karuppana, MD Chief Medical Officer Valle del Sol suganyak@valledelsol.com

The Heart of Patient Care and Connection

2022 MCMS MEDICAL STUDENT ESSAY CONTEST WINNER

Anxiety grips at your chest as you sit in the muted clinic waiting room. A worry pulls persistently at the back of your mind, the same one that drew you here today in search of answers. As you stare down at your lap, turmoil pours from a television screen hanging in the corner of the room. A news anchor rages on about a war across the world, mass shootings that seem to occur daily, and the rising prices that you yourself have felt the burden of weighing down on your own shoulders. The never-ending stream of opinions, facts, stories, worries, and fears, creating an everpresent static in your mind. Your phone sends a vibration down your leg, pulling your attention for the 3rd time since you sat down, displaying bold red headline “Arizona Braces for Additional Water Cuts Amid Megadrought.” As your thumb hovers above the link, your name is called, and you are

summoned to the back for your appointment. While the chaos rages on within your mind, a brisk knock at the door interrupts for a moment and initiates the doctor’s entry.

As physicians in training, one skill stands above all else when it comes to reinforcing the front lines of healthcare in our world today: communication. We are all trained in the same basic sciences, dedicating hours to learning the medications, recognizing typical and atypical

clinical presentations, and appreciating the intricacies involved in diagnosis, treatment, and prevention. Each student has their own story about how they were drawn towards the field of medicine. At the heart of this journey, a sense of empathy, curiosity, and desire propelled each of them towards a life dedicated to helping others. These intrinsic drivers, along with the years of academic study, give us the sturdy steel with which we can craft our tools of treatment. It is important to note that these alone do not produce the most effective weapon to battle against the barriers of healthcare. An article published by the World Health Organization reported that a scientific brief released on 3/2/2022 showed a 25% increase in global prevalence of anxiety and depression. Learning to communicate is what forges our raw steel into a blade. Carefully crafted, it

cuts through the chaos to reach people in their vulnerability and isolation. We can use our words to drive a path through the fear and misinformation and provide the hope, kindness, and support that is so often in short supply.

It is good communication that lies at the heart of the very best physicians. Communication takes empathy from an internal experience to an external expression that can wrap another person in a blanket of comfort. Skill in communication allows for years of education to be conveyed in simple summary to any lay person, no matter their background. It helps us as caretakers to create and maintain healthy boundaries for ourselves as well, to ensure that our own self care is not neglected and forgotten. Clear communication allows every member of a team to come together, combining the efforts of many into one, inspired to collectively achieve a singular goal. Anyone who has spent time working in healthcare knows all too well that the knowledge and resources you have available only go as far as the patient feels motivated. “Leadership is communicating to people their worth and potential so clearly that they come to see it in themselves” – Steven R Covey. How we communicate determines whether patients leave the office feeling empowered or further lost in the disorder of the world. It is this communication that is often undervalued, undertaught, and is often the uncredited skill that allows us to inspire others to be the best version of themselves. ■

By Sarah Osborne, OMS-IV Midwestern University

“Communication takes empathy from an internal experience to an external expression that can wrap another person in a blanket of comfort.”

Building on a Medical

LegacyFamily

A second generation orthopedic spine surgeon, Chris Yeung, MD, shares his thoughts on insurance and its impact on his practice.

With a quiet confidence, Dr. Chris Yeung is successfully building on a medical family legacy. A proud Asian American physician, his journey has been forged through talent, skill, and shrewd business acumen while never forgetting the traditions instilled in him.

Chris Yeung, MD, is a board-certified orthopedic spine surgeon. He earned his undergraduate degree from University of California San Diego. He then graduated in the top 5% of his medical school class at the University of Southern California Keck School of Medicine. He completed orthopedic residency at the University of California, Irvine Medical Center, and a spine surgery fellowship at the USC Center for Orthopedic Spine Surgery in Los Angeles.

A PHYSICIAN, ALWAYS ON THE MOVE

Dr. Yeung has three different types of days: one in which he’s seeing patients at his clinic, Desert Institute for Spine Care (DISC), and a second in which he’s conducting three or four surgeries at a hospital or ambulatory surgery centers. The third type of day is when he serves as an orthopedic spine consultant for several major league sports teams, covering games, working closely with head trainers and team doctors to diagnose injuries, develop treatment plans, and execute the plans.

Dr. Yeung is the team spine consultant for the Arizona Diamondbacks, Arizona Cardinals, Chicago Cubs, Kansas City Royals, Colorado Rockies, Los Angeles Dodgers, LA Angels, Cincinnati Reds, and Arizona State University. He not only works with professional sports teams but is also part owner of Phoenix Rising FC.

Dr Yeung is active in clinical research serving as the principal investigator in various FDA studies, including lumbar artificial disc replacement, cervical artificial disc replacement, and Coflex interlaminar stabilization.

LIKE FATHER, LIKE SON

Growing up, Dr. Chris Yeung didn’t have far to look when it came to a role model. His father,

Anthony Yeung, MD, is a renowned orthopedic spine surgeon well known for his development of ultra-minimally invasive spine surgery and endoscopic spine surgery. Emigrating from China with his mother, Dr. Anthony Yeung grew up quickly, learning to speak only English at home and developing a strong work ethic and an entrepreneurial spirit that led him to found what has become DISC. As he was considering the field of medicine, Dr. Chris Yeung leaned on the motivation of an immigrant family to succeed in America.

DISC is a multi-location practice that Dr. Yeung credits Stephanie Helston, JD, for helping to steer in the right direction. Her executive experience running the practice and staff allows Dr. Yeung and his four partners Justin Field, MD, Nima Salari, MD, FAAOS, Joshua Abrams, DO, and Mark Wang, MD to focus on medical care for patients.

INSURANCE'S IMPACT ON DISC

Since launching in the 1920s with a focus on surgery, emergency visits, and births, commercial health insurance carriers have evolved to cover a much wider range of services. The large influence of

“Unfortunately, health care costs have skyrocketed, and insurance companies are trying to control costs. A big way they do it is to just reflexively deny care"

private insurers over medical decisions is often contentious with physicians. Dr. Yeung shares how his practice works with insurance carriers.

DISC currently receives payments from around 50% commercial insurance, 30% Medicare, 10% cash, and 10% worker’s compensation. The Medicare percentage has risen with the aging population, while cash payment is preferred since it cuts out the middleman and, in most cases, motivates the patient to do well before, during, and after the procedure.

“Unfortunately, health care costs have skyrocketed, and insurance companies are trying to control costs. A big way they do it is to just reflexively deny care,” says Dr. Yeung.

The administrative burden on physicians and their practices has gotten worse, he says, “From physicians being second-guessed about their recommendations to medical denials to guidelines that may or may not be guidelines from one day to the next.” The consequences of the stress and red tape lead to strained doctorpatient relationships because patients are made to wait while in pain, with some told their treatment or procedure will be denied. Those patients often take out their frustrations on the physician and staff.

Even though insurance companies hired medical directors and installed peer-to-peer appeals for delays or denials, the process has become more difficult. DISC staff use a lot of their time in the back-andforth exchanges for authorizations, losing precious time with patients. Long delays lead to frustrated patients who give up or change insurance companies, which ends or restarts the process. Even when surgical procedures are approved, insurers often dictate what implants the surgeon can and cannot use.

Dr. Yeung says, “When you interject a third party in the relationship between doctor and patient, it’s always going to be frustrating. The regulations and requirements for approving needed care continue to change and continue to be more restrictive. So, it inhibits the relationship.”

Another source of physician apprehension is vertical integration of insurance companies buying private practices and hospitals. It becomes a scary prospect for private practices to compete. “The potential for an insurance company to narrow their networks to only employed physicians is real,” states Dr. Yeung.

WHAT CAN BE DONE

“Insurance companies can build more collaborative relationships with physicians, if they can again trust physicians to do what’s right, which a vast majority do,” says Dr. Yeung. He acknowledges that the costs of health care have skyrocketed, yet second guessing physicians on their medical diagnosis make the relationship more adversarial and can harm patients. Insurance companies collect a ton of data on physicians and if physicians meet quality and cost effectiveness targets, it would be nice to get the benefit of the doubt on requested care.

As a free market physician, Dr. Yeung placed less focus on fighting with insurance carriers and more on building a strong practice with the right partners and superior outcomes. He has never been a proponent of more government intervention when it comes to physicians and the relationships they have with commercial insurance. Yet, he understands the need for physicians to team up. He says, “There’s some safety in numbers, so becoming a bigger practice may be a good direction.” He admits there are positives in having better negotiating power with large group practices, but ultimately a practice that produces superior

From left: Justin Fields, MD; Nima Salari, MD, FAAOS; Chris Yeung, MD; Mark Wang, MD; and Joshua Abrams, DO.

outcome will attract more patients willing to treat regardless of their insurance status.

Chris Yeung

On the Personal Side with Dr.

Q: If you could describe yourself in one word, what would that be?

A: Meticulous

Q: Do you have family? Pets?

A: I met my wife, Helen, in college and now have two daughters in college and a son in high school.  Ashley is a senior at the University of Notre Dame, Lauren is a freshman at SMU, and Dylan is a freshman at Brophy.

We have four dogs and two cats.  We had only two dogs, but one day my wife and daughter came home with two sibling puppies from a dog rescue/adoption event they were volunteering at!  My daughter loves snakes and we often catch a gopher snake or ground snake in our yard and keep it for a few weeks.

Q: Do you have a hidden talent most people would not know about you?

A: I bow hunt for bull elk.

Q: What career would you have been doing if you were not a physician?

A: I honestly can’t envision myself doing anything else.  As a teen, LA Law was a popular TV show which glamorized the law profession and I thought of becoming an attorney.  I quickly realized writing was not my strongest suit and focused on science.

Q: What book are you reading now, or recently?

A: Outliers by Malcolm Gladwell

Q: What is your favorite sports team?

A: Phoenix Rising FC of course!  We hope to eventually become an MLS expansion franchise.

Q: What is your favorite movie?

A: Top Gun Maverick is a recent favorite; nostalgic, patriotic, fun.

Q: What is your favorite food?

A: Din Tai Fung soup dumplings

Q: What is favorite local restaurant?

A: Nobu is hard to beat.

Q: What is your favorite activity outside of medicine?

A: I love being in the outdoors fishing, bow hunting, SCUBA diving, and hiking. Enjoying nature is so relaxing and energizing at the same time. SCUBA diving is like traveling to another world with amazing sights, sounds, and the feeling of weightlessness floating underwater.

Hospital diversification or aligning with different hospital systems is also an important solution to adapt to the growing influence of insurance companies. Some insurance plans align themselves with certain hospital systems and only cover treatment at those hospital systems. So private practice physicians should be on staff at multiple hospital systems in order to care for these patients.

Finally, Dr. Yeung believes that physicians can overcome obstacles set by private insurance companies by advocating for patients by having systems in place that help staff and surgery schedulers be on top of each patient’s delay or denial and the appeals process to secure coverage. Also, physicians need to have exceptional interpersonal skills when it comes to physician bedside manner with patients. That builds a positive relationship with each patient and makes them feel prioritized, ensuring each patient remains committed to their treatment or procedure.

WHAT WE LEARNED

Dr. Christopher Yeung has always appreciated the positive influence his father Dr. Anthony Yeung has had throughout his medical journey. Yet, he is confident and can speak with conviction of growing into a successful physician and practice owner by travelling on a path built by his own hard work, dedication, and working with people he can trust. Despite constraints often placed on his practice by working with commercial insurance carriers, Dr. Yeung and DISC are successful because they have the right attitude toward patient care, take care of their employees, and are nimble operators always looking to be proactive. ■

By Edward Araujo Managing Editor Arizona Physician earaujo@mcmsonline.com

What DOCS Arizona are Saying

Why or why not?

No, they transfer you multiple times to get to a person who can assist. They cannot find previous messages from prior calls on the member. They do not care to work with you as the provider when things are not in your control, like COB issues. —Beth Hoff, DO

Yes, except for when they deny prior authorizations or give us conflicting information. It’s a huge burden and I need extra employees due to the many phone calls. —Sarah Patel, MD

No, insurance companies simply interfere with good healthcare to save themselves money; all in the guise of “quality.” They are less concerned with quality unless it can show in a metric in a way that saves them money. Saving money is fine if it is not on the backs of my patients or myself. —Steven Reeder, MD

No, VERY inefficient in communication/authorization. Improper denial of payment and care services to patients. —Robert Cravens, Jr., MD

No, it is extremely hard to even talk to someone or get help when needed. —Sheena Banerjee, MD

No, in my experience the insurance companies don’t reimburse physicians right away or enough for our work. —Rebecca Abraham, MD

No, time consuming and frustrating. —Klee Bethel, MD

Insurance carriers add complexity to medical care, much of which may be unnecessary and done solely to put up barriers to care. —Deva Boone, MD, MBA

No, their efforts to cut costs tend to lead to conflicts about what is best for the patient. —Arthur Chou, MD

No, reimbursements for physicians are slim to none for the services and care provided to patients. —Linda Sodoma, DO

No, long holds. Multiple hoops to get meds. Always long roadblocks that I don’t have time for, and I become more aggravated. People at insurance company can’t even say meds let along know what they are approved for. —Randy Gelow, MD

No, too much red tape, time spent on authorizations and denials. —Bertrand Kaper, MD

Read more about what Arizona Docs are Saying when it comes to insurance at arizonaphysician.com/docs-insurance

Are your interactions with insurance carriers generally positive?

Insurance role is to protect their clients from high medical bills but with soaring medical costs and the non-insured, the normal family pays extremely high premiums and then has high deductibles as well. —Sheena Banerjee, MD

They dictate all care and rates of care. —Rebecca Abraham, MD

Insurance seems to dictate what the type and extent of care is provided. Paul Coulombe, MD

They are dictating how we practice medicine and limit the care we can provide. —Earl Labovitz, MD

Integral part but perhaps we would all be healthier without it. —Klee Bethel, MD

Insurance largely determines where and how patients can receive health care. Insurance companies, with their low and declining reimbursements, are contributing to the depletion of private practice physicians. —Deva Boone, MD, MBA

Private insurance is the ruination of healthcare in America. —Glenn Brown, MD

I think insurance plays a heavily negative role in today’s healthcare system for both patients and providers. Patients’ coverage is horrible, and they must pay out of pocket for most anything. Most insurances now are only beneficial for a catastrophic event. Providers are almost losing money with most insurance companies as reimbursements are so slim.

—Linda Sodoma, DO

Headaches. RECORD profits with multiple roadblocks. —Randy Gelow, MD

They have successfully intertwined themselves into the fabric of the healthcare system. Unfortunately, their motivations are profit driven not patient driven. Until this changes, we are doomed to continue this pathetic relationship. —Bertrand Kaper, MD

Insurance has far too much power in the health and wellbeing of our populations. The admins (CEO, CFO, CIO, managers, administrators) of insurances effectively lump into one pile thereby dehumanizing the professionals (physicians, PAs, NPs, CRNAs, PT, OT, PharmD, etc...) by labeling them “providers.” The term confuses patients and healthcare workers alike who don’t know who is treating them and who is on the team. —Tammy Penhollow, DO

They need to work better with the providers. They need to be held accountable for things that are said and printed. They need to pay for work provided and not get out of it every chance they get.

—Beth Hoff, DO

They should not control the delivery of healthcare, or my patients hard earned healthcare dollars. They are just not very good at it. —Steven Reeder, MD

Channels need to be created for employers to contract directly with provider groups for services. —Robert Cravens, Jr., MD

Clients who are not sick a lot should be rewarded with lower payments and better plans, while people who do not take care of their health should be more accountable. —Sheena Banerjee, MD

It should be affordable to patients and doctors should get paid for their level of education and value. —Rebecca Abraham, MD

I would prefer a common formulary and open access of physicians. —Paul Coulombe, MD

One payer system for everyone. —Glenn Brown, MD

As a nation, we should have one level of basic health insurance for everyone and there could be other private health insurance plans layered on top of that. —Arthur Chou, MD

Let providers prescribe what they are comfortable with. In the end, what we do will likely cost less than 6 weeks of PT just to get an MRI which we need anyways - they just paid for 6 weeks of PT, and MRI, AND now surgery as well.

—Randy Gelow, MD

If that role should change, then how so?

What role do you think insurance plays in today’s healthcare system?

for pre-authorization?

No prior auths should be required. We are physicians! We use our knowledge, not insurance criteria, when prescribing. —Sarah Patel, MD

Eliminate them! I have never found them useful! They are simply a barrier erected to impose frustration theory on physicians. (i.e., the more barriers put in the way; the more physicians will give up trying). —Steven Reeder, MD

Automate the process. The phone is the choke point. Insurers know this and use it to their advantage. Docs can’t afford to pay people to wait on hold.

—Robert Cravens, Jr., MD

Physicians should not have to deal with this. Meds and tests should be overall affordable. —Rebecca Abraham, MD

Over 90% are authorized so other than to harass physicians and delay care I don’t know why it exists. —Klee Bethel, MD

Many of the pre-authorization requirements seem designed only to provide barriers to patient care, not to ensure quality care. Put up enough barriers, and it isn’t even worth it to get pre-authorization. The insurance company saves money just by putting up that (unnecessary) barrier, knowing that it won’t be worth it for me to fight for it. —Deva Boone, MD, MBA

Create one website, similar to CoverMyMeds, that would handle all pre-auths and prior-auths; and/or health insurance companies to increase the number of staff to handle this process and who are trained to manage the vast majority of pre-auths and prior-auths so that all you need to do is make 1 phone call, speak to 1 person, and address the pre-/prior-auth with 1 call. And/or, as AI and interoperability improves, this process could become more automated given most clinics use an EHR. —Arthur Chou, MD

More automated systems i.e., by phone, or online to obtain pre-authorization for surgeries/ in-office procedures rather than waiting on hold for up to 2 hours on hold with an insurance company. —Linda Sodoma, DO

Accept our documentation rather than question it. —Bertrand Kaper, MD

Go to a direct primary care (DPC) or 100% cash pay practice. Stop negotiating with insurance. —Tammy Penhollow, DO

What are your suggestions to decrease the work

There needs to be an easier way for everyone to take care of the member without all the paperwork hassle and time spent on the phone changing things every visit. —Beth Hoff, DO

Outlaw insurance companies from denying any service prescribed by a physician. Put the power back into the hands which it was entrusted to in the first place. Trust the Hippocratic Oath to be fulfilled.

—Steven Reeder, MD

Give us a phone number that we can talk to a real person about the issue we are having.

—Sheena Banarjee, MD

Ability to communicate directly with the claims dept to resolve unpaid claims or to the review dept to get paid. —Earl Labovitz, MD

The insurance carriers do not care about their relationships with small private practices like mine. —Deva Boone, MD, MBA

Make them accountable to follow AMA and CMS coding rules. —Glenn Brown, MD

Invite more input from physicians from the community; not just as a one-off meeting or “town hall,” but an on-going relationship to help implement new plans and then provide repeated feedback so that protocols and policies can be continuously improved upon.

—Arthur Chou, MD

Streamline insurance companies and don’t allow carveouts - physicians nowadays can’t even begin to understand what plans cover what services because there are so many exclusions and carveout plans.

—Randy Gelow, MD

Pay physicians what they are worth. No other professional has been subject to decades of undermining the value of services offered other than medicine. Ridiculous.

—Bertrand Kaper, MD

Read more about what Arizona Docs are Saying when it comes to insurance at arizonaphysician.com/docs-insurance

Learn more about the participating physicians

Beth Hoff, DO Arizona Kids Pediatrics

WEB | Arizonakidspediatrics.com

Sarah Patel, MD Sonoran Sleep Center WEB | Sonoransleep.com

Steven Reeder, MD Mesa Family Physicians WEB | Mesafp.com

Robert Cravens, Jr., MD Tucson ENT Associates PC WEB | Tucsonent.com

Sheena Banerjee, MD All Kids Urgent Care WEB | MySickKid.com

Rebecca Abraham, MD Hospice of the Valley WEB | hov.org

Paul Coulombe, MD Covenant Care Family Medicine

Earl Labovitz, MD Mesa-Tempe Allergy & Asthma Clinic

Klee Bethel, MD Sonoran University

WEB | Sonoran.edu

Deva Boone, MD, MBA

Southwest Parathyroid Center

WEB | Southwestparathyroid.com

Glenn Brown, MD

Glenn H Brown MD PLLC WEB | Browndermatology.com

Arthur Chou, MD Horizon Health & Wellness WEB | hhwaz.org

Linda Sodoma, DO Life Care for Women

WEB | Lifecareforwomen.com

Randy Gelow, MD

Banner Health

WEB | Bannerhealth.com

Bertrand P Kaper, MD

HonorHealth Medical Group WEB | HonorHealth.com

Tammy Penhollow, DO

Precision Regenerative Medicine

WEB | PrecisionMedprp.com

What steps should be taken to improve the relationship between insurance carriers and medical practices?

A CONVERSATION WITH

Southwest Fertility Center

From left: Dr. Vinay Gunnala, Dr. Sujatha Gunnala

Meet Drs. Sujatha Gunnala and Vinay Gunnala, likely the only mother-son fertility doctors in the country. We sat down to discuss how Southwest Fertility Center has evolved since its founding by Dr. Sujatha Gunnala 42 years ago and how the next generation is preparing for the future of fertility care.

Learn more about Southwest Fertility Center by visiting

ARIZONA PHYSICIAN: How has fertility treatment changed since 1980?

DR. SUJATHA GUNNALA: The world’s first test tube baby was born in 1978 in England, while I was in my fellowship training. I never would have imagined what would emerge from those early days. Back then, we had no formula for media to even grow the embryos. We would attend conferences, where researchers published their recipes. Back then an egg retrieval was a laparoscopic surgery done in the hospital under general anesthesia whereas now we can do perform the procedure under conscious sedation trans-vaginally in the office.

AP: As a younger doc in the field, what’s your take on recent advances?

DR. VINAY GUNNALA: The process for harvesting eggs takes only about 20 minutes with a vaginal procedure. So, there’s no scars in the belly, no incisions, much lower risk. The ability to fertilize eggs in a dish made huge advancements in the 90s as you can now inject one live sperm into each egg. ICSI has allowed millions of couples with a severe male factor to get pregnant with IVF. Other important advances have been the ability grow embryos in culture to a blastocyst (day 5 or 6) and to genetically test embryos with a biopsy. These advances allow us to select the best embryo for transfer, minimize risk of multiples.

AP: Have you seen growth in the number of patients seeking infertility treatment?

DR. VINAY GUNNALA: The incidence of infertility is increasing and now it affects one in eight couples or 12% of the general population. The reasons are multifactorial, but the biggest contributing factor is delaying pregnancy with more advanced female age. Like the national trends of infertility, our practice volume has increased about 15% per year for the last three or four years.

AP:What have been some of the biggest challenges over the past five or ten years?

DR. SUJATHA GUNNALA: Many of the insurance companies cover diagnostic tests and but most consider infertility as an elective treatment. Infertility is a symptom of underlying gynecological disorders and after completing the diagnosis, patients can have a very good chance of conceiving.

AP: Would you say your interactions with insurance carriers is generally positive or negative?

DR. VINAY GUNNALA: It's a benefit for the patient when it's done in the correct way but, by the same token, working with insurance carriers makes it more challenging to practice. But at the end of the day, if it gives the patient a benefit in terms of being able to afford treatment, then it's our job as an office to go through the hurdles. When I started four years ago, it was maybe 15% and today 30 to 35% of our patients have some fertility treatment coverage.

“We had to write a letter and fight to get paid. In this field, we're lucky to get $0.20 on the dollar.”

—Sujatha Gunnala, MD

AP: What role do you think insurance plays in today’s healthcare system?

DR. SUJATHA GUNNALA: Health care should be a human right. How it is distributed, how it is implemented, and practiced are very important. Even educated people without insurance neglect their health and by the time they come for care, diseases are very advanced. It is important for people to have insurance, but carriers should not have as much control as they do.

AP: Reimbursement rates. Do you think they're reasonable?

DR. SUJATHA GUNNALA: I did a surgery on a patient over five hours with severe endometriosis, pain, symptomatic and all that. We submitted to the carrier and our insurance person brings me the check. It was one cent. One cent because the insurance carrier didn’t know the codes. We had to write a letter and fight to get paid. In this field, we’re lucky to get $0.20 on the dollar. There is so much written off.

DR. VINAY GUNNALA: There is a trend of fertility doctors to not do as much surgery because they are not getting reimbursed as well. Referring those surgical cases out while staying in the office and doing their officebased procedures is reimbursed higher than a 5-hour surgery. No matter what I see on the operative report or what I see in the pictures and who I talked to, doing the actual surgery prevents some loss of information.

AP: How much is the burden of pre-authorization on your practice?

DR. SUJATHA GUNNALA: Over eight hours a day. The repetition of paperwork for each treatment is not using our staff’s time efficiently.

DR. VINAY GUNNALA: The insurance side of fertility has been the biggest challenge for me. There are easily three to four employees who cover aspects of pre-authorization, but every employee must be aware of the process. If you miss one step there is a delay in getting authorization and these delays may seem like an eternity for a patient who must wait to start treatment.

AP: What are your suggestions to decrease the burden?

DR. VINAY GUNNALA: A big problem is the lack of bundling of treatment. When starting with less aggressive treatment like IUIs or ovulation induction medication, most couples conceive in the first three cycles or up to six. Insurance authorizes one cycle at a time and then our staff has to complete all of the paperwork again and that takes another 15 business days. I think if insurance carriers could see these inefficiencies in their process and trust our medical expertise, it would relieve a little bit of the workload.

DR. SUJATHA GUNNALA: Why do they have to make medical decisions? We submit everything with the diagnosis and treatment, and we know that the treatment works most of the time.

AP: I understand the practice lost a COE insurance contract. What impact will that have on Southwest Fertility?

DR. VINAY GUNNALA: COE, or center of excellence, sometimes called an institute of excellence (IOE), is a label given to a specific fertility practice by the insurance company.

It limits where a patient can get fertility treatment as that patient will only have fertility coverage at a center with that label. One of the big negatives of the COEs and IOEs is they’re very subjective. Insurance companies will analyze the pregnancy rates of that fertility center annually, but each companies’ criteria are different. This past year, with the same annual dataset, we lost one COE label and got accepted with a different insurance company. Different goalposts.

AP: How are renovations in the Phoenix location a game changer?

DR. SUJATHA GUNNALA: With a higher volume of patients, we needed more space to do our procedures and recover multiple patients at a time. Before we scheduled procedures 1-2 hours apart and that was not efficient for our patient flow.

DR. VINAY GUNNALA: The air filtration system in our new IVF lab is 10 times purer than you would find in any standard hospital. We were always happy with our rates but, in the last year, the growth of embryos has had a significant change from prior, so there's no doubt that it made a difference.

AP: What’s it like working with your son?

DR. SUJATHA GUNNALA: When it comes to patient care, medical decisions, I don't interfere because he's very well trained. With my experience, I may see something and say, “That’s not going to work,” and he says, “Mom, you don’t know.” That happens. ■

Interested in having your medical practice showcased in Arizona Physician? Email us at info@arizonaphysician.com.

LEGAL CORNER

Contracting with Commercial Insurance Payors

Caveat Medicus

It is no secret that the process of negotiating a contract with commercial health insurance plans can be unpleasant or even futile for healthcare providers. These contracts are lengthy and seemingly impenetrable. Although the review of these contracts can be a challenge, failure to undertake a careful review may expose you to significant unknown, and even uninsured, liabilities. Your ability to negotiate this type of contract depends on many factors, including the size of your practice, the scope of your practice’s geographic coverage, the number of other in-network providers with similar specialties as you, and other factors. This article lists some of the more problematic payor contract provisions and discusses some of the issues that arise from such provisions.

INDEMNIFICATION

Indemnification and hold harmless provisions allocate legal risk between the parties. The following is an example of a mutual and limited indemnification provision: Indemnification. If Payor is sued solely as a result of Provider’s negligence, willful act, or omission, Provider agrees to defend and indemnify Payor. If Provider is sued solely as a result of Payor’s negligence, willful act, or omission, Payor agrees to defend and indemnify Provider.

The above provision simply documents what the common law provides in most states. However, payors often include much broader indemnity provisions in their Contracts. The following is an example:

Indemnification. Provider agrees to defend, indemnify and hold harmless Payor from all liability arising directly or indirectly from Provider’s provision of services.

In some states (including Arizona), this type of provision might obligate you to defend and indemnify the payor for claims based in part on your conduct; in effect, you become the insurer of the payor. This type of provision significantly expands your potential liability. Worse, professional liability insurance carriers typically exclude coverage for this additional contractually assumed liability. This exclusion results in your having to defend and indemnify the payor at your own expense.

TERM AND TERMINATION

Many contracts have an initial term of at least three years and automatically renew for additional terms of one to three years, unless the provider or payor gives written notice of non-renewal within a certain time. As payment rates change, automatic renewal can be problematic for providers who are not aware of the automatic renewal.

Learn more about how to contract with insurance payors by visiting arizonaphysician.com/contracting-ins-payors

Termination without Cause. Most contracts include these provisions, which permit either party to terminate the contract on relatively short notice (e.g., 60-120 days). Some providers assume they are entering into long-term arrangements with the payor, and do not realize that the payor can terminate the contract and the provider’s right to participate in the payor’s network without any stated reason.

Some providers prefer contract terms that allow the provider to terminate the agreement without cause on relatively short notice. However, when this occurs, there is a risk that the payor’s beneficiaries (particularly those who are under active treatment) will not be appropriately transitioned to another physician. Typically, the contract will obligate you to continue to provide covered services to beneficiaries during a transition period after termination. If the payor fails to arrange for the transfer of responsibility for the patient’s care in a timely fashion, and an adverse outcome results, you could still face licensing or malpractice actions for alleged “abandonment.”

Termination Upon Material Breach. Most contracts include terms permitting either party to terminate the contract upon a party’s material breach of the contract terms, following a notice and cure period.

Termination For Cause. Most contracts also include terms permitting the Payor to terminate the contract immediately upon the occurrence of certain events, including:

 Conviction of certain crimes; exclusion from participation in government health care programs; discipline by any licensing board or medical staff; and,

 Commission any act the payor deems to be detrimental to a member’s health or safety.

PAYMENT TERMS

Nearly all payor contracts will prohibit you from billing the payor’s beneficiaries for services covered by the payor. Most contracts include terms obligating the payor to pay you for covered services rendered to payor’s beneficiaries according to “Clean Claims,” but only to the extent the payor determines such services to be medically necessary. Many provider/payor disputes related to non-payment of claims are premised on the payor’s assertion that the services rendered were not medically necessary.

Arizona’s Timely Pay & Grievance law states that payors must adjudicate clean claims within 30 days after their receipt of the clean claim, or within such other period specified by the payor contract. Accordingly, to ensure timely payment, it is critical that the contract: (1) clearly define what constitutes a “complete, clean claim;” (2) state that claims will be deemed to be “complete and clean” unless the

payor notifies you that additional information is needed within a predetermined short period of time after submission; and (3) obligate the payor to pay complete, clean claims within a predetermined short period of time after submission.

GRIEVANCE AND DISPUTE RESOLUTION PROCESS

Nearly all contracts with payors provide for some form dispute resolution other than a jury trial. The contracts typically require you to first exhaust the payor’s informal dispute resolution process before initiating a formal proceeding. As such, it is important for you to obtain and review all applicable payor policies. Disputes related to the payment of claims often have stringent timelines and procedural requirements, and failure to meet such requirements may leave you without recourse as to the disputed claim. Most contracts include terms requiring the parties to submit to binding (non-appealable) arbitration of their disputes.

MEDICARE ADVANTAGE (MA) AND AHCCCS

REQUIREMENTS.

Depending on the plan type, the contract may include terms requiring you to comply with AHCCCS and/or MA rules and regulations, including prohibitions or restrictions on your ability to contract with individuals and entities outside of the United States, or on your transfer or storage of data outside of the U.S. If you directly or indirectly contract with offshore individuals and entities to provide billing, revenue cycle management, or other services involving the provision of beneficiary health information to parties located offshore, compliance with these terms can be problematic.

Other important terms to thoroughly review include any quality review and utilization requirements; non-disparagement provisions; and change of control and assignment provisions. Typically, payors present the contracts as nonnegotiable, and many smaller practices find this to be true. Despite that, it is a good idea to at least attempt to modify problematic terms. Where those efforts are unsuccessful, you should evaluate the contract carefully, and decide whether the benefits justify the risks.

This article is made available for informational purposes only and is not for the purpose of providing legal advice. You should contact your attorney to obtain advice with respect to any particular issue or problem. ■

By Miranda A. Preston, JD Shareholder Milligan Lawless, PC miranda@milliganlawless.com

Ways Your Practice Can Improve Insurance Reimbursements

The current healthcare insurance reimbursement process is a challenge for most private practices. Getting paid on time and in full takes coding skills, billing experience and seamless revenue cycle management (RCM) processes.

Whether you’re a new practice or a seasoned private physician, optimizing your reimbursement process is one of the most effective ways to increase revenue. And with added revenue, you can grow your business and care for more patients in your community.

Here are five steps you can take today to improve reimbursement from payers.

CREATE AN EFFECTIVE INSURANCE VERIFICATION PROCESS

Knowing whether a patient has active, valid insurance is the first and most important step of your reimbursement process. If a patient receives services at your practice but doesn’t have an active insurance plan, you won’t be able to file a claim and may not get paid for those services.

To learn more about ways your practice can improve insurance reimbursements , please visit arizonaphysician.com/ins-reimbursements

Creating an insurance verification process at your practice can help make sure you catch any inactive plans before a patient comes in for treatment. Consider running batch eligibility checks a week or two in advance and create follow-up steps for patients whose plans are inactive.

SEND PATIENT ESTIMATES TO INCREASE UPFRONT COLLECTIONS

One of the best ways to improve payer reimbursement is to collect that reimbursement upfront before you start the claim process. You can do this by sending payable estimates before the patient’s appointments. Patients are often more likely to pay a balance for services if they understand the costs upfront.

You’ll also be able to increase upfront collections if you use a communication channel that your patient prefers. That means exploring options for SMS text and email estimates and statements.

ESTABLISH AN EFFICIENT REVIEW PROCESS

One of the best ways to improve reimbursements is establishing a review process for your billing and coding. Beyond claim scrubbing, this process can help ensure you’re reimbursed as much as possible for patient care.

It’s important to note here that we’re not talking about upcoding (submitting a claim for a more complex or expensive service). Rather, we’re talking about using the most accurate and specific CPT code possible for the service you’re providing.

ORGANIZE AND DOUBLE-CHECK PAYER DETAILS

Your team must have a handle on your payer contracts and processes — this is a cornerstone of a smooth claim and reimbursement process. If your payer information is disorganized or inaccurate, you’re unlikely to get paid for the claims you’re filing.

Here are some essential payer details and steps your team needs to consider when improving the reimbursement process:

 Make sure your provider credentialing is accurate and up to date.

MAKE CLAIM CORRECTIONS AND SUBMIT RECONSIDERATIONS

Instead of adding to your write-offs, create a process for correcting claims and submitting reconsiderations. If you make appropriate corrections and submit them along with detailed patient notes, the payer may reimburse your claim after all.

Alongside your claim correction and reconsideration process, make sure your team knows to collect detailed documentation for each patient. That includes encounters, treatments, tests and procedures, and any pre-authorization or pre-certifications you had to get before the treatment. This documentation can help support your claim reconsideration and increase the likelihood of full reimbursement.

GROW REVENUE BY OPTIMIZING YOUR INSURANCE BILLING

Improving a few areas of your insurance billing process can go a long way in maximizing reimbursements and helping your practice thrive. Whether it’s improving your insurance verification, sending estimates, or finding a better way to review claim documentation, these steps will give your business the cash flow it needs to grow.

If your insurance reimbursements aren’t bringing in the revenue you need, Gentem Health has the expertise to make a difference in your bottom line. With a team of billing experts and proprietary, AI-powered software, we help practices spend less time on billing and more time growing their businesses. ■



Don’t forget about insurance verification and ensure your team always submits the claim to the correct insurer.

 Verify that you’ve mapped the correct payer and payer IDs in the claim submission software.

By Melanie Graham RCM Marketing Manager Gentem Health melanie.graham@gentem.com

“Instead of adding to your write-offs, create a process for correcting claims and submitting reconsiderations.”

L. Gaefke, MD

thoughts on the impacts of insurance on private practice

Q: Are there any insurance carriers you do or do not accept? Why? Why not?

A: The practice accepts most commercial insurances and Medicare to serve the pediatric, adult and geriatric community in the Valley.

Q: Do you see insurance carriers as a partner or roadblock to providing care?

A: Both. Carriers allow patients to search for physicians in the area within their specialty of choice, make reviews available to other patients, and encourage patients to seek preventative care. Nevertheless, carriers can unfortunately also be a roadblock when it comes to physicians’ ability to choose individualized management plans, specifically choice of medication class or brand.

Q: Which treatments are most often denied by insurance carriers? How do you respond?

A: Specific class or brand of inhaler medications for the management of asthma are the most often denied medications that I have seen. Also, nonsteroidal topical regimens for atopic dermatitis, such as Crisaborole, are frequently denied. Biological therapies for uncontrolled chronic idiopathic urticaria, asthma, and atopic dermatitis, can at times be difficult to get approved.

Particularly when it comes to inhalers, given the frequency in the lack of coverage, there is dedicated staff in the practice to handle prior authorization requests. As the physician, I also direct letters to the carrier detailing indication and medical necessity, if needed. Additionally, patients are aware of the roadblocks that they may encounter with an inhaler or inhalers of choice, therefore if denied, they are instructed to request either the pharmacy or insurance carrier to provide me with a list of covered inhalers under their individual plan.

Lastly, samples of biologicals and inhalers are provided by manufacturers to aid with this process.

Q: Is it relatively easy or difficult to join insurance networks?

A: Physicians at the practice have been able to join insurance networks without difficulty.

Q: Are there improvements you would like to see in the healthcare system regarding how physicians interact with insurance carriers?

A: Yes. When a physician’s recommendation for a specific treatment needs to be reviewed by a carrier’s representative, a peer-to-peer review within the same specialty would be optimal, to prevent delays in care. Physician’s autonomy in practice preference should also be respected. In my experience, a carrier can require a physician to obtain a full schedule DEA, for example, even if not a necessity to the specialty or physician’s preference, in order to participate.

Q: Do you offer telehealth visits and get reimbursed at the same rates as in-person?

A: The practice offers telehealth visits when in person appointments are not feasible for the patient. Reimbursement to the practice has varied in the past years based on insurance carrier and of course during and after the COVID 19 pandemic and its associated evolving coding policies. ■

CLAUDIA L. GAEFKE, MD Allergist & Immunologist Allergy Asthma Clinic, Ltd.

info@allergyasthmaclinicltd.com

Claudia

shares her

Arizona Physician Magazine

326 E Coronado Rd, Suite 101 Phoenix, AZ 85004 (602) 417-2303 information@arizonaphysician.com

MUTUAL INSURANCE COMPANY OF ARIZONA®

MUTUAL INSURANCE COMPANY OF ARIZONA®

To learn more about MICA or to request a quote, call 800-681-1840 or visit info.mica-insurance.com/mcms.

To learn more about MICA or to request a quote, call 800-681-1840 or visit info.mica-insurance.com/mcms.

“Protecting our insureds’ interests is at the core of everything we do in Claims. Nobody ever wants to be involved in a claim, but MICA claims representatives are always ready to help our insureds through the challenges posed by any claims they are involved in.”

“Protecting our insureds’ interests is at the core of everything we do in Claims. Nobody ever wants to be involved in a claim, but MICA claims representatives are always ready to help our insureds through the challenges posed by any claims they are involved in.”

Stephen Collins, CPCU, AIC MICA Assistant Claim Manager

Stephen Collins, CPCU, AIC MICA Assistant Claim Manager