Corvallis Osteopath Struggles with Providence Billing
Dr. Sandra Sleszynski is a well-respected osteopath working out of Crossroads Premiere Health Care in Corvallis. Her patients have seen remarkable improvement in their conditions, and although her treatments are not inexpensive, insurance coverage has made them accessible for the patients who need them most. All of that changed when, in January 2013, Providence Health Plan stopped covering her treatments and denying patient reimbursements.
Doctors of osteopathy are trained and licensed as traditional medical doctors, but also may learn osteopathic manipulative treatment (OMT). Similar to chiropractic care but involving all of the doctor’s medical training as well, OMT, is a manipulative treatment that brings the musculoskeletal system into alignment.
Historically, this treatment has been covered by most health insurance policies. However, many DOs are now seeing frequent audits from insurance companies that are refusing to pay. In Sleszynski’s case, she and many of her patients feel that she is being targeted by Providence not just because of the treatments but because she pushed back. The loss of insurance coverage has forced many DOs to stop offering OMT, or to offer treatments on a cash-only basis, limiting accessibility for many people who need them but can’t afford them at full price.
Until Fall 2009, Sleszynski had been a Providence provider. At that time the insurance company audited her clinic.
“They decided I wasn’t doing enough family practice-only,” she said, “and too much OMT.” After trying to explain her practice and methods to Providence’s medical director, she says, “I got a letter kicking me out of the network.” The timing of the letter caused problems for her patients, she said, because “They were planning on me being in-network. They’d have changed providers January 1 if they’d known this was going to happen. They got stuck with an insurance provider who wouldn’t cover what I was doing.”
In late 2011, other insurance companies including ODS (now Moda Health) and Regence BlueCross BlueShield also started audits of Crossroads’ billing practices. And in 2012, Providence extended their audits to some of Sleszynski’s earlier claims and demanded reimbursement from her as well as her patients for claims they stated were coded improperly or lacked proper charting support.
Sleszynski claims that her billing practices are not a problem. She follows the standards set out by the American Medical Association (AMA) and the Current Procedural Terminology (CPT) manual. Set and regularly reviewed by the AMA, the CPT is the most widely accepted medical nomenclature used for medical reporting and coding.
Sleszynski tried to settle with Providence. She enlisted another osteopath to do an external review of her records and find an appropriate settlement amount. “But Providence said no,” Sleszynski said. “They wanted the full amount because they said the documentation didn’t support it, and they weren’t going to pay for any of it. We were feeling a little singled out.”
David Walls, executive director for Osteopathic Physicians and Surgeons of Oregon, says that the state association is unclear about why Providence would continue to deny these claims. “It’s really tough,” he said. “I don’t know if Providence is specifically targeting her, but we are certainly concerned about it. There doesn’t seem to be any information about why the claims are being denied. If it’s for cost savings, that doesn’t make sense. This treatment is very effective for pain. Often, patients can get off medication and have an active lifestyle, which leads to lower costs for the health insurer.”
In Fall 2013, as Sleszynski’s case escalated, Providence sent letters threatening to ask the medical board to revoke her license for fraud and abuse. Sleszynski felt that Providence’s approach was itself intimidating and abusive, “and my lawyer wrote them a letter that said, if you’re going to take her to court, stop sending nasty letters and just do it.” Those threats have not advanced.
Efforts to involve the state insurance commissioner have come up short. In Corvallis, many Providence customers are public employees who work for Oregon State University. Healthcare for these individuals goes through the Public Employees Benefits Board (PEBB). That agency hired Providence as its HMO, and is outside the jurisdiction of the insurance commissioner, said Sleszynski. “There’s no one to police Providence on our behalf.”
Patients Caught in the Middle
Many of Sleszynski’s patients don’t have the time, energy or money to appeal Providence’s decisions. “One patient did go through the appeal process last December,” said Sleszynski. “She pleaded the case, showed documentation, and answered questions.” The ruling was overturned, and the patient was paid, but it appears to have been an isolated win.
“They’re continuing to not reimburse patients,” Sleszynski said. “We’ve lost patients and volume. We’re trying to match them up with people who can care for them, but it’s not easy. I have an advanced degree in osteopathy [Fellowship in the Academy of Osteopathy, or FAAO]. I have extra training that these patients were benefitting from, and they aren’t getting the results they need.”
Sleszynski’s patients are fiercely loyal to her, in many cases because they’ve seen improvement in their conditions that they had been unable to find anywhere else. “I have patients who were able to get off medication who had to go back on,” Sleszynski said. “Or patients who had complications after going off treatment, which led to the need for surgery. Many of my patients would be fine if they were just getting reimbursed for out-of-network charges, but they’re not. Providence is rejecting the entire claim.”
Wilma Shockman is a patient of Sleszynki’s who credits the doctor with saving her life. A series of misdiagnoses through Providence hospitals led to a 60-pound weight loss and multiple kidney and liver problems, said Shockman, “Got my body into a state where it just can’t fight anything.” Sleszynski’s treatments helped make the pain tolerable. When Providence abruptly stopped covering the treatments unlike their previous decisions, Shockman had to cut back, and now suffers greater pain more frequently and for longer periods.
“To me,” said Shockman, “this is about an insurance company that got mad at a doctor. But we are the ones paying. If it weren’t for Dr. Sleszynski, I might not even be on the Earth. I will continue to pay out of pocket as often as I can. But it’s just not right.”
In several cases, lack of payment from Providence is also affecting patients’ secondary insurance coverage. “For some,” said Sleszynski, “they aren’t even saying they’re denying. They’re just saying they don’t have proper documentation and tying up the claim. If patients don’t get a denial from their primary insurer, they can’t submit to the secondary.”
The Oregon Insurance Division forwarded requests to the Department of Consumer and Business Services, which told The Lund Report they cannot comment on an ongoing case. Communications officer Lisa Morawski stated in an email, “If consumers or providers feel that an insurer is unlawfully denying claims, they should contact the Insurance Division, and we will look into it.”
At press time, Providence Health Plans had not responded to repeated requests for comment.
Temple can be reached at [email protected].