To: Health Services Board, Fred Sanchez, Protect Our Benefits
From Lois Scott, Protect Our Benefits
These discrepancies were brought to my attention by a distinguished local Doctor of Oriental Medicine and Licensed Acupuncturist, who has been in practice in San Francisco for 40 years.
The concern this provider expressed is for the interruption or denial of services to patients who receive treatments in conjunction with cancer treatment or for critical pain management.
Specifically, both the prior UHC and current BSC plans provide for 24 medically necessary acupuncture or other specialty musculoskeletal treatments annually. However, the following differences and difficulties have been revealed as the provider tries to work with this benefit.
BSC has subcontracted with American Specialty Health (ASH) to administer the program and to qualify patients, rather than handle it directly as had been done by UHC. Rather than facilitate patient needs, ASH has become a gate-keeping intermediary and has reduced compensation to practitioners.
Problems include:
- Need for patients to obtain recertification of medical necessity at or after their fifth treatment
- “Out of Network” providers not contracted with ASH, are not able to utilize electronic billing and have difficulty communicating efficiently, for example using paper forms and post office.
- “In Network” providers are offered insufficient reimbursement such that they can only cover costs of very short, less than ten-minute treatments.
The net result of the BSC subcontract with ASH will be: fewer practitioners willing to work with HSS Medicare advantage PPO retirees and less access to specialty treatments by those now receiving them or needing to receive them.
In terms of future cases and complaints to HSS and POB, there has not been much time for service cut offs or denials to have occurred, especially with communication constraints imposed by ASH. In our HSS retiree beneficiary population we have a number of firefighters who have cancer related to occupational hazards and who also utilize specialty treatments. Navigating cut offs of service may be especially difficult for those with critical illness in midst of treatments.
The subcontracting to ASH by BSC will result in degradation of an important palliative benefit previously available from UHC on an efficient and cost feasible basis.
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