Dear Rep Fisher: Insurance Commissioner's office cannot get past lies of BCBSNC PPO re: non-availability of colonoscopies in western NC

Letter to Representative Susan Fisher: Fisherla@ncleg.net

Marsha V. Hammond, PhD: Clinical Licensed Psychologist, Asheville/ Waynesville, NC

e mail: hammondmv@netzero.com cell: 404 964 5338

RE: NC Department of INsurance cannot see past the song & dance of BCBSNC re: screening colonoscopies

November 24, 2008

Dear Susan Fisher, my NC House of Representatives person:

There are still no screening colonoscopies for citizens of western NC w/ BCBSNC insurance plans....2.5 million of us across the state. Most lately, the NC Department of Insurance has fallen for their song and dance which seems to be associated with coverage, but in fact, is not.

To make it all the more hilarious, BCBSNC just sent me a letter suggesting that I have a screening colonoscopy!

I talked to the insurance commissioner's office, specifically, Doris Edwine, tel 919 807 6773. I wrote her a letter.

BCBSNC simply sent her a list of the gastroenterologists in Buncombe county. As I have done before, I called them. They told me what they have told me before, namely that their practices will not do office based screening colonoscopies. They do only clinic based screening colonoscopies...like they told me a year ago.

I have been researching this for a year now (please see the blog which does not reflect the six months prior to the first post in June, 2008). Nothing has changed. I would like to know what the NC State Legislature which oversees BCBSNC is going to do about this.

BCBSNC PPO will not pay for clinic based screening colonoscopies and the gastroenterologists will not do the office based ones, I assume, as associated w/ the risk of having a patient move around on the table and then puncturing their colon which means that ---literally----you better have created your will cause you're a dead person.

My file number: 2008-10-01135.

It would be useful to have my NC State Representative check on this matter, I believe.

Thank you.

Marsha V. Hammond, PhD

Medicaid Primary Care Providers fall short of recommending cancer screening: WHILE BCBSNC PPO offers no affordable screening colonoscopies to insured

Cancer Screenings Are Available For Many, But Not Used
October 22nd, 2008 by allsoch
Medicaid recipients age 50 and older are falling short of national cancer screening objectives. According to a report published in the October 13 issue of Archives of Internal Medicine, only about half receive colorectal, breast, and cervical cancer screening tests that the government recommends.

(cut and paste):
http://www.canceraids.org/2008/10/22/
cancer-screenings-are-available-for-many-but-not-used/

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BCBSNC PPO plans (families pay close to $700/ month for these, as does my 3 member family) will not pay for screening colonoscopies within 2.5 hours of major metropolis, specifically, Asheville, NC. BCBSNC gives song and dance and run-around which state legislators, who are supposed to oversee BCBSNC, fall for again and again. BCBSNC PPO plans (3/4 million peoplein NC have this plan) will only pay for OFFICE BASED screening colonoscopies and gastroenterologists mostly do not offer these but rather CLINIC BASED screening colonoscopies.

CLINIC BASED screening colonoscopies are not the treatment of choice or medically necessary treatment as patients who squirm w/o anesthetic IV Versed (part of CLINIC BASED screening colonoscopies), run the risk of colon perforation and DEATH.

I have a question into the NC Insurance Commissioner as to this matter as I have not been able to get any state legislator to act on this pressing matter.
Marsha V. Hammond, PhD: Clinical Licensed Psychologist
blogsite overseeing BCBSNC: http://madamedefarge2scutinizingbcbsnc.blogspot.com/

Can the NC State Insurance Commissioner help re: no screening colonoscopies for BCBSNC PPO insured???

Here is the letter I wrote to the insurance commissioner of NC:

"BCBSNC has been telling me for almost 2 years that there is no office based colonoscopy (they will only pay for this; they will not pay for a clinic based screening colonoscopy) available anywhere in western NC except for Boone, NC, over 2 hours away. It is impracticle to try to go for a colonoscopy full of Fleet's enema or some similar preparation, trying to drive to get to the appointment, having to stop everywhere along the way in order to use the bathroom---for 2 plus hours. I have written them; I have talked to my state legislator; I have talked to OTHER state legislators; I have talked to the NC STate Legislature Standing Committee via e mail. I get no where. I would like for my $700/ month/ 3 family members who are healty---to pay for a clinic based screening colonoscopy---only has to be done every 10 years unless there is something detected-----closer to home---as in Asheville, NC, a city of over 100,000 people. Can you help or what do you say about this matter? For more detail information---more than you want to know---I have created a blogspot specific to BCBSNC and these problems....."

Will BCBSNC be accurately audited in terms of reasons for asking for hand-outs----whileas NC State Legislature looks the other way?

At least someone is watching the matter----and it sure is not the NC STate Legislature which is supposed to be doing that as associated w/ its 'standing' (maybe they're lying) committee:

".....The auditor has not shown the same deference to BCBSNC that legislators exhibit, so hopefully the report helps explain the higher administrative charges.

Word is that the auditor could release one or both of the audits in early November. We'll be watching....."

http://pulse.ncpolicywatch.org/?p=1533#more-1533

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more from that fine article at NC Policy:

September 30, 2008
State Health Plan is singing the Blues
Posted at 1:59 PM by Adam Linker

I haven't seen much media coverage of the latest news from the North Carolina State Health Plan, which insures more than 650,000 people across the state. The only documents I've seen are not encouraging.

In reports to the General Assembly and the SHP Board of Trustees , Executive Director Jack Walker projects that the plan will lose between $264 million and $280 million for fiscal year 2008/2009.

The original budget estimated that the SHP would have a $228 million cash balance by the end of July 2008, according to Walker. The actual cash balance at the end of July was $72 million.

Why the shortfall?

Dr. Walker stated that both medical and pharmacy claims increased 7.2% during the past fiscal year as opposed to the projected increase of 1.9%.

And what accounts for the original rosy projections? Higher than expected administrative payments to Blue Cross and Blue Shield of North Carolina. That's right, the same insurer that was overcharging the state's Health Choice program is also sinking the SHP....."

BCBSNC: poor coverage AND NOW THEY SAY THEY'RE IN THE RED : State Auditor Merritt to look at BCBSNC books

July 24, 2008
Les Merritt will examine the State Health Plan
http://pulse.ncpolicywatch.org/?p=1343#comment-18407

Posted at 1:30 PM by Adam Linker

State Auditor Les Merritt says he is going to look into the problems at the State Health Plan to figure out what is behind the $115 million "disparity between the initial forecast and the current projection and will focus on oversight and financial forecasting."

There is still a great deal of confusion about what happened at the SHP that led to lawmakers ousting the former Executive Director George Stokes.

Merritt says there have been "many calls" to the auditor's office asking about the shortfall.

The SHP is overseen by a board of trustees and the legislative committee on employee hospital and medical benefits. ....



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Dr. Hammond's reply to that blog



While not in the domain of 'getting to the bottom of what happened to that money', Mr. Merritt, what happened to our coverage under BCBSNC PPO out in western NC?

Seems that nothing gets noted unless it happens in Raleigh.

Adam Sears has stated that as far as he knows, the state legislators have BCBSNC 'The State Plan.' Are the state legislators from western NC getting access to screening colonoscopies, as covered by BCBSNC, while the citizens and their families with the BCBSNC PPO plans are NOT?

There are NO screening colonoscopies available, which will be paid for by BCBSNC PPO, short of almost 3 hours from Asheville, a major metropolis in western NC.

I therefore assume, as some cynically waxing physicians out here, if BCBSNC isn't just assuming that by the time that colon cancer is diagnosed for some of this, well, heck, we'll be using Medicare and they'll be out of the picture.

For more details see: blogspot:http://madamedefarge2scutinizingbcbsnc.blogspot.com/

Marsha V. Hammond, PhD Clinical / Health Psychologist,
Asheville/ Waynesville, NC

BCBSNC 'The State Plan' gets $100 million rescue from NC STATE LEGIS WHICH WAS SUPPOSED TO BE OVERSEEING BCBSNC

BCBSNC 'The State Plan'/ 'Blue Options' and BCBSNC PPO,appear to be the SAME PLAN.

When reporters/ journalists cover stories about BCBSNC's The State Plan, without mentioning the connection to BCBSNC, citizens do not get that we are talking about a PRIVATE insurance company which is supposed to be overseen by the NC STate Legislature but which, in actuality, does pretty much as it pleases and just like the big banks, once they have made all their private money, come the SHORT FALL, the citizens are supposed to PAY FOR IT.

See:

http://pulse.ncpolicywatch.org/?p=1321

July 17, 2008
State Health Plan Crisis: Were overseers asleep at the switch?
Posted at 3:49 PM by Adam Searing

The House Appropriations Committee met this afternoon and passed out a bill to authorize $100 million from the state’s rainy day fund to backstop the state health plan which is reportedly facing a serious shortfall. Apparently this shortfall was completely unexpected and now has the General Assembly in an uproar. Any clear information on the amount of the shortfall and why the shortfall happened is simply not available – at least not publically. Apparently the General Assembly is looking into the matter with auditors and other staff, but this oversight role is just beginning.

Why hasn’t this happened before however? The State Health Plan isn’t a small part of government. It insures over 600,000 state employees and their families. Good oversight should not allow shortfalls like this to happen. The software health insurance companies use now can accurately project claims and costs for years. There is a structure in place to oversee the plan so no one person – like the recently fired executive director – is solely in charge of the plan.

BCBSNC Gets Shielded by Professional Organizations: no parity for BCBSNC PPO 'State Plan'

BCBSNC Gets Shielded by Professional Organizations : no parity for BCBSNC PPO ‘State Plan’

IMPLEMENTATION OF MENTAL HEALTH PARITY - HOUSE BILL 973

EFFECTIVE DATE OF PROVISIONS JULY 1, 2008


I would like to know why, when people talk about this vague ‘State Health Plan PPO’ (see below, Cameron statement), they do not mention the fact that we are talking about basically the only game in town in terms of group plans for families and individuals who are not members of group plans (read: they have no employer sponsored health insurance).

State Health Plan PPO = BCBSNC PPO Plan.

They are avoiding stating that it is associated w/ BCBSNC, that’s why.

It is unbelievable that BCBSNC is supposedly overseen by NC State Legislature. When you call a state legislator’s office, they advise you to call the BCBSNC ‘Government Affairs’ employees.

These ‘Government Affairs’ employees are hired by BCBSNC to keep a lid on complaints while the state legislators apparently look the other way.

My 3 member family has BCBSNC PPO. We pay over $650 month for this PPO. There are over 2 million PPO BCBSNC members in NC.

BCBSNC PPO plans will not pay for clinic based screening colonoscopies (see referenced information at: http://madamedefarge2scutinizingbcbsnc.blogspot.com/).

There are NO gastroenterologists in western NC who will do an ‘office based’ screening colonoscopy except for one practice in Boone, NC, fully 2-3 hours away from the most populated part of western NC, specifically, Buncombe county, the location of Asheville.

Now you’re telling me that BCBSNC somehow got out of having to adhere to mental health parity (H973) which was signed into law.

Moreover, NC Psychological Association is stating, as per Sally Cameron, Executive Director:

“…The parity law does not cover the State Health Plan PPO plans…. a strategic decision because the PPO plans have a broader benefit and includes parity for substance abuse…..”

Physicians are able to bill BCBSNC at an 80/20 formula with the patient or other carrier picking up the 20% while mental health providers are stuck at the 60/40 level as associated with mental health coverage.

Furthermore, in terms of ‘implementation problems’ how are state funded clients as managed by the LME’s included----(OR NOT)-----as mental health parity ‘supposedly’ created this (as per Cameron):

“HB 973 provides that nine (9) diagnoses are covered at full parity with physical illness “ bipolar disorder, major depressive disorder, obsessive compulsive disorder, paranoid and other psychotic disorder, schizoaffective disorder, schizophrenia, PTSD, anorexia nervosa and bulimia. The means there can be no durational limits set in insurance/managed care plans for these nine diagnoses. Insurance/managed care plans can use utilization review criteria to manage a mental health benefit.”

Western NC has 2 LME’s which cover 25% of NC 100 counties. They manage state funded mental health clients, the 'working poor' who have no health insurance.

Governor Easley, and assumably subsequent governors are advocating that these LME’s also manage Medicaid. This means that their ability to impact psychologists is going to INCREASE not decrease.

Western Highlands Network LME has stated that only Personality Disorders will receive more than 8 sessions of therapy and then only if Dialectical Group Therapy is included.

I would like to know how H973 applies to this matter.

Smoky Mountain Center LME has stated that no Basic Level Services are available for state funded clients. All therapy is subsumed under Community Support Services which is being rapidly defunded; is scrutinized under post payment reviews; and requires people who utilize it to undergo 20 hours of unpaid training.

I would like to know how H973 applies to this matter.

You asked, Sally, that NCPA members give you some feedback re: this implementation matter:

“Please note the FOLLOW-UP section and let us hear from you about an implementation issue. “

This is my statement about this implementation: BCBSNC is being shielded by professional mental health organizations in this state.