The Rules Run Backward

OPINION. This is a point-of-view piece, not news reporting. It relies only on facts reported, sourced and dated in that week's issue.

If you run an independent practice, you already know how this works: you have to be right ahead of time, and the payer gets to be right after the fact.

Look at this week. Cigna added 37 codes to precertification effective Oct. 1 and told everyone Oct. 16, in a notice that doesn't even list the codes. In Texas, BCBSTX posted its updated IONM policy on Oct. 20 with an effective date of Oct. 9. Two different payers, same move: the rule starts before you can read it. Try telling a payer your claim was effective two weeks before you submitted it.

Then there's accuracy. A federal audit found CareSource got 952 of 952 sampled QPAs wrong. Not most. All of them. Those are the numbers that anchor what we get paid for out-of-network care. Meanwhile CMS has proposed holding MA plans accountable for directory accuracy, which I support, and the AMA warns plans would answer by writing that duty into our contracts. So when the payer's math is wrong, it's an audit finding. When the directory is wrong, it may become our contract problem.

And nobody should mistake any of this for hardship. Elevance beat and raised its guidance this week. UnitedHealthcare and Humana are ending MA plans for about 1 million seniors, and those patients will be at our front desks in January with new cards and new rules.

So here's my ask. Do the boring work: check Cigna's list against your October cases, flag those MA patients for January eligibility checks, and treat every QPA as a number to check, not a number to trust. Then write CMS by Dec. 15 on the directory rule. Tell them accountability belongs with the plans, and the paperwork shouldn't land on practices.

We can't stop payers from posting rules after the fact. We can stop being surprised by it.

This is an opinion piece. The facts it relies on are sourced and dated in this week's issue.