Del. Donoghue seeks to save doctors' fees

February 09, 2005|BY TAMELA BAKER

ANNAPOLIS - A Washington County lawmaker is trying to stop the sun going down on laws that require health management organizations to reimburse trauma physicians outside their company networks at competitive rates.

The laws are due to expire June 30.

Del. John P. Donoghue, D-Washington, told the House Health and Government Operations Committee on Tuesday that his bill would require HMOs to continue to reimburse trauma physicians outside their networks who give trauma care to HMO members at the current rate of either 140 percent of the rate paid by Medicare or the rate the HMO was paying to other physicians for the same services in the same geographic area.

Representing the Maryland State Medical Society, attorney Joseph A. Schwartz said the group supports Donoghue's bill, in part because in Maryland, if a trauma physician doesn't have a contract with a patient's HMO, he can't bill the patient for the balance of his charges.


Before the original laws were passed in 2000 and 2001, Schwartz noted that HMOs were required to pay physicians what was "usual, customary and reasonable." But it was HMOs that determined what was usual, customary and reasonable.

Committee Chairman John A. Hurson, D-Montgomery, noted that the committee was grappling with the issue of doctors leaving Maryland because of low reimbursements from insurance companies.

"Help us figure out how to keep insurance companies from driving physicians out of this state," he said.

Schwartz replied that he saw Donoghue's bill as a "stop-gap" measure, and that a more permanent fix is needed.

Trauma physician David A. Hexter, of Elkton, Md., suggested that committee members follow Florida's lead and change the law to say that HMOs must pay the usual and customary charge rather than usual and customary rate.

"I can tell you that's a lot different from a rate the insurer might pay," he said.

These charges, he added, would vary by physician, the region where the practice is located and the clients it serves.

Florida maintains a database in which charges are periodically surveyed, he said. HMOs must pay in the 80th percentile of those charges.

Hexter said 20 percent to 40 percent of the workload in his emergency room would be affected.

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