 PEF fights formula that
sticks members with big chemo bills
In an effort to protect its members with cancer from
huge, unfair bills for chemotherapy, PEF has taken its
case to an arbitrator who has slated a hearing on the
matter for October.
PEF contends the insurer, United HealthCare (UHC), is
using the wrong basis for calculating how much it should
pay non-participating providers for chemo-therapy drugs,
and is sticking PEF members with too big a share of the
tab, which often runs to thousands of dollars.
When PEF was made aware of the problem by a member who
was being billed for thousands of dollars by two
different non-par hospital extension clinics, the union
filed a class-action grievance directly to Step 3. It
calls for the state to instruct UHC to stop limiting its
reimbursements for prescription drugs billed by a non-par
provider to the average wholesale price.
“Instead, UHC should base its payments on the usual
“reasonable and customary” formula it uses for
other medical services,” said PEF associate counsel
Lisa Newmark. “The R&C charge should be
calculated using the actual charges the providers are
billing patients for these drugs.”
The Governor’s Office of Employee Relations denied
PEF’s grievance on April 15, saying it considered
UHC’s use of the AWP consistent with the PS&T
contract. The grievance is now scheduled for arbitration
in October.
While PEF is pursuing a remedy to this problem through
the contract-grievance process, the basic issue also has
come up in other cases not involving PEF which are under
review in the courts and by the state Insurance
Department.
An article in the July-August issue of The Communicator
warned Empire Plan enrollees of the financial hardship
they could face if they receive outpatient chemotherapy
at a non-par physician’s office or clinic.
Plan members can hold their out-of-pocket expenses down
to the usual copayment of $15 or less by buying their
chemo-therapy drugs at an Empire Plan par pharmacy or
through the plan’s mail-order pharmacy.”
|
The Communicator
September 2002
The Official Online Edition of
The New York State Public Employees
Federation
Inside This
Issue:
Features
PEF backs Pataki re-election
bid
PEF Board votes to back
candidates in ’02 races
PEF joins fight against
soaring Rx costs
Early retirement windows
opening
Q&A on 25/55, ERI
9/11; One Year Later:
‘Everything is different’ since 9/11
PEF fights for counseling
Victims’ families
grateful for PEF’s help
Contributions of PEF
activists missed
PEF to dedicate memorial
Departments
President's Message:
Endorsements and Loyalty
You Said It: Member's
letters this month
Member Mobilization: 8 steps
to success
Legislative Action:
Retirement, whistleblower laws
Nurses' Station: Help make
new future for nursing
Retirees In Action: Lucky to
get 1% COLA
PEF Membership Benefits
Program & Travel Corp
Union Matters
2002 Convention Preview
PEF researcher’s
discovery offers hope
Members show interest in
PS&T negotiations
Division 236 at Parole fully
mobilized
Members at Labor Dept. win
back rights
PEF fights big chemo bills
PEF vets keep wagering safe
bet
PEF wins OT pay
Highlights of PEF Exec
Board’s meeting
Member’s kids wins
scholarships
Support true charities, job
security
GET OUT THE VOTE!
Other Links
Professional Directory
Members' Classified
Member Communicator Feedback
Do You Prefer The Online
Edition?
How To Advertise Here
PEF Pride Store
Last Month's Communicator
The Communicator Staff
Questions on this site?
Email the comwebmaster.
 Register here on the PEF Member
Network.Click on pefonline@pef.org
 Click
Here email notice
when next issue is online
Site Map What's New Search
|