NOW COMES Intervenor, Maine Medical Association ("MMA"), through its
undersigned counsel, and submits this prefiled testimony of Georgia A. Tuttle, M.D.,
consistent with the terms of the Superintendents Procedural Order of November 4,
Q: For the record, please identify yourself and your current employment.
A: Georgia A. Tuttle, M.D. I am a self-employed physician dermatologist and I am board
certified in my specialty.
Q: Where is your practice located?
A: 129 Mechanic Street, Lebanon, New Hampshire.
Q: Would you please describe your education and training in your present field?
A: I completed my undergraduate degree at the University of Maine in Orono in 1976. I
went to medical school at Tufts University School of Medicine in Boston and graduated in
1980. I did my internship in internal medicine at the Faulkner Hospital in Jamaica Plain,
Massachusetts. I then completed 3 years of dermatology residency at the Dartmouth
Hitchcock Medical center where I was Chief Resident in Dermatology.
Q: Would you be able to provide us with a curriculum vitae?
We will attach this as Tuttle Exhibit #1.
Q: Through your practice, have you been involved with the American Medical Association
A: Yes, Ive been a member of the AMA since I was in medical school and over the
past four or five years, I have been the alternate delegate to the AMA from the State of
New Hampshire. What that means is that I represent the physicians of New Hampshire at the
national level. I have testified in reference committee, on the floor of the AMA House of
Delegates, traveled with the President and Chairman of the Board of the AMA on our
National House Call program during the most recent Presidential debates here in New
Hampshire, and have been appointed to both a special advisory committee of the AMA-BOT and
to a national ad hoc committee on reorganization of AMA-OMSS (Organized Medical Staff
Section). I sit in the House of Delegates where AMA sets policy on all issues surrounding
patient care and the practice of medicine for the physicians in this country.
Q: Through your involvement with the AMA, have you had opportunities to speak with New
Hampshire physicians and other physicians in the New England area about current
developments in the health care delivery system?
A: Yes, I speak with New Hampshire and New England physicians, but also physicians from
around the country. The AMA meetings do provide an opportunity for physicians from around
the country to share information and ideas and that is where we set the national policies.
Q: Please describe your involvement with the New Hampshire Medical Society.
A: I am currently the immediate past president of the New Hampshire Medical Society
(NHMS). I served as President from January 1999 through January 2000.
Q: Did you hold positions prior to becoming President of the NHMS?
A: Yes, I have been on the NHMS Executive Committee for a number of years and I have
held positions as a delegate at large, vice-speaker of the house, vice president,
president elect, president and now immediate past president.
Q: Through your testimony you are representing yourself and not the NHMS?
A: Thats correct. But because of the experience I had as President I do have a
perspective on this particular matter.
Q: Could you discuss your involvement in Anthem Companies Inc.s (Anthem) purchase
of Blue Cross Blue Shield of New Hampshire (BCBSNH)?
A: It was during my NHMS presidential year that Anthem came forward and made an offer
for BCBSNH and so it was in my role as president that I took part in all of the intervenor
meetings, the discussions and negotiations with Anthem. I also was involved in hearings
with the New Hampshire Insurance Department during the final hearings before the closure
of the sale and I cross-examined the executives of both BCBSNH and Anthem in that role.
Q: During that process, were you in touch with New Hampshire physicians about their
feelings regarding Anthems purchase of BCBSNH?
A: Yes, I was.
Q: How did you go about getting their opinions and identifying those issues?
A: It was the role of the NHMS Executive Committee to gather concerns and the entire
Executive Committee polled New Hampshire physicians about some of their issues. We
developed a list of questions, the answers for which it was my responsibility to find. We
also published information in the NHMS newsletter and asked physicians to contact us with
a list of their concerns or any questions they might wish to be included.
Q: Based on what you were able to gather from New Hampshire physicians, what were the
major concerns with Anthems purchase?
A: I think there were a number of concerns. Specifically, they included the "most
favored nation" clauses and the "all products" contract clauses used by
Anthem in other states. There were issues with the designated and separate provider
networks clauses that were outlined in those contracts. We represented our members who
were insured with BCBSNH and who were concerned about whether products would continue to
be available to them. From a patient perspective, we were concerned about whether Anthem
would be able to provide the kind of service that BCBSNH had been able to provide
including the availability of all the current products that BCBSNH offered. Other issues
that arose were concerns about the Benchmark Satisfaction Surveys Anthem had done in the
Midwest which pointed to a number of specific problems encountered by participating
physicians in those states. We were concerned about outsourcing the credentialing process
that Anthem might use, claims processing, prompt payment, access to physicians by patients
in the northern part of the state and whether Anthem would be able to continue to provide
the kind of care our patients needed.
Q: Through your discussions with physicians, did you have any concerns about
Anthems management practices or the integration of Anthem systems in order to
facilitate physician billing and physician relations with Anthem?
A: Yes we did. Traditionally here in New Hampshire with BCBSNH, physicians were able to
talk directly with medical directors who had been active practicing physicians in New
Hampshire and had gone into administrative positions as medical directors. These
physicians/medical directors understood the way medicine is practiced in New Hampshire,
they understood the way care is provided. They understood the issues of distance and
travel, our rural hospitals and the kinds of service areas that we have. We were concerned
that under Anthem some of the close contact that we have had with the medical directors
might be lost in New Hampshire. We were concerned that Anthem might regionalize many of
its processes outside of New Hampshire and we would be talking with someone in another
state or someone halfway across the country about some of these kinds of issues that have
always been and we felt needed to continue to be handled within the state.
Q: As part of Anthems proposal in New Hampshire did they mention or talk about a
regional New England plan?
A: In our original discussions with Anthem when they first came to New Hampshire, that
was talked about at some length. As the process moved forward, that discussion of
regionalization diminished somewhat and there was more emphasis on Anthem being in two or
maybe three states in New England with less of a regional approach. There was discussion
however about regionalization of particular business practices - billing, claims
processing - and we were concerned that many of these processes would be moved out of New
Hampshire or New England where we would have very limited access, except by telephone, to
the individuals that could help New Hampshire physicians with billing and claim processing
questions. I also heard concerns about possible premium increases once Anthem took over
and questions arose about whether Anthem would use New Hampshire premium dollars to
purchase other BCBS plans in other states rather than spending those dollars on patient
care. Physicians wanted someone to protect patients from that possibility. Physicians were
also worried about their ability to have access to data. Data is the future of medicine
and claims processing is the first place to collect the data and begin to study practice
patterns. We are concerned about whether Anthem would be a partner and share data as
BCBSNH had done.
Q: Since the purchase of the BCBSNH was finalized, have you been told of any movements
toward a regionalization?
A: I think thats been a continued concern of physicians. We know that Anthem is
now doing business in Connecticut and New Hampshire. They are attempting to purchase Blue
Cross Blue Shield of Maine and that would bring them to three out of six New England
states. I think that from a business prospective, one must recognize the potential for
economies of scale if Anthem BCBSNH should regionalize services. So this regional concept
has continued to be a concern.
Q: Since the purchase of BCBSNH by Anthem, have you had discussions with physicians
and/or clinic managers regarding Anthems business practices?
A: Yes I have. Three important issues came up during those discussions. One was the
issue of Medicare cross-over claims. When one sees a Medicare patient and submits a claim
to Medicare, one provides information about secondary insurance policies that the patient
may have. After Medicare processes the claim and pays its portion, it automatically
forwards that claim to the secondary or next insurance company. What New Hampshire
physician practices have encountered since Anthem took over BCBSNH is that these Medicare
cross-over claims that are being sent from Medicare to Anthem are not
processed or paid. None of the other insurers in New Hampshire have created that problem
for physicians. The second issue that has arisen is notification by Anthem to the
physician practices about these potential problems. These problems did not come to light
until various physician practices complained to Anthem about the failure of the claims to
be paid. It was only then that Anthem informed physician practices about this situation.
Thirdly, the current software that Anthem is using negates modifiers. Modifiers are
additional numbers placed after procedure numbers that explain that procedure in a little
more detail. For example, if you operate on both sides of the body or if you do a
procedure within so many days of a previous procedure, the modifier explains that both
left and right sides were treated or why you might have seen the patient so quickly again
post-op. The software Anthem is using basically makes those modifiers disappear and so
claims are denied when they would be paid if the modifier was recognized.
Q: Going back to the Medicare cross-over issue, if the electronic procedure does not
work to pay the physician, how have physicians been paid for these services and have those
different payment methods caused problems?
A: After a medicare claim is processed, one receives something called an EOMB which is
"Explanation of Medical Benefits." If a claim is not sent on to the secondary
payer, it becomes the responsibility of the physician to get a copy of the EOMB, to make a
photocopy of that document, and then submit the secondary claim with EOMB to Anthem on
paper. This means physicians have to fill out another claim form and mail that with the
EOMB. That involves a lot of staff time and a lot of hassle. It takes a lot of time to get
all those pieces of paper together and one cant file those electronically because
you have to have a copy of that EOMB attached to the secondary claim.
Q: With regard to the modifier issue, has that issue arisen at all on a national level
and if so, for your service on behalf of AMA, what have you done regarding this issue?
A: Yes, this particular issue has been in the national arena for a number of years. To
go back a little bit, the AMA owns the copyright to the CPT Coding Book which is the bible
of codes and modifiers explaining medical procedures and any modification to those
procedures. For a number of years independent companies have taken this CPT Coding Book
and made electronic programs that one uses to do claims processing. Some of these
companies have written their programs in such a way that modifiers are completely ignored.
The AMA has been attempting to work with these companies to get them to correct the
software. I have been a participant in the discussion of the issues at the AMA House of
Delegates and with the American Academy of Dermatology. This situation has continued to be
a problem in some insurance companies and those companies that produce the software have
not been willing to correct the problems. To put this issue in perspective even Medicare
with its many problems, recognizes and honors modifiers in their claims processing. This
problem exists with Anthem and its software.
Q: If these modifier problems arent corrected, does it take more time for
physicians to submit and be paid for the claim?
A: The answer is yes. Once a claim is denied then one often has to fill out an appeals
process form or at least one has to make a phone call to the insurer, get through and talk
to the right person to find out how to go about refiling the claim. Every time you refile
a claim you do the same work again and again. It is time consuming it delays payment and
it also detracts from staff doing other necessary work.
Q: Have you heard of any other concerns expressed by other physicians or clinic
A: Yes. Under BCBSNH, physician practices have told me that they received very
personalized service. If they called with a problem or they wrote a letter they received a
personal response, a letter signed by an individual whom they could call. Under Anthem,
physicians tell me that they call with problems or write with concerns and they may get a
verbal response at best, but they dont get anything in writing and they often feel
that their complaints go unrecognized. They feel that the problems that they have
complained about are not being solved since Anthem has taken over BCBSNH. For example, one
physician practice told me that when they used to write with concerns or call with
concerns that they would receive a personal letter from David Jensen, BCBSNH CEO. Now they
sometimes get a promise from an employee, whose name they may not be given or recognize,
so that they really feel that the service they get now is very impersonal and not helpful.
Q: Do you have any specific examples about physician practices having to go through
great pain to get reimbursed for services?
A: Yes. In one specific example, a physician practice told me that after submitting 66
claims, all 66 of those claims were denied. This had to do with Anthems computer
system rejecting all claims because a modifier was attached. The computer system did not
recognize the modifiers even though the correct modifier was being used. When the
physician practice recognized that those 66 claims had been denied and called Anthem, they
were told that they would need to fill out a three-part inquiry form for each of
the 66 claims.. The physician practice will have to reprocess all 66 of those claims and
do a separate individual inquiry form for each. This extra administrative work is very
time consuming and expensive and should not be required.
Q: Regarding the development of Anthems New England regional plan, did you have
any further concerns or input on this issue?
A: When we first began our discussions with Anthem in the spring and early summer,
there was some discussion about a regionalized program. Those issues seemed to disappear
somewhat as we moved through the process. But when we were discussing them actively, we
asked Anthem if they could guarantee that our New Hampshire physicians would have
leadership roles in critical decision making for patients, particularly on medical policy
issues. We were never able to insure that meaningful New Hampshire physician input would
continue should a regional program be developed.
Q: Is there anything else you would like to discuss regarding Anthems regional
A: One of the issues that came forward early on in our discussion as we reviewed
example contracts that Anthem utilizes in other states, is a clause called the designated
provider network. This is a clause in the contracts that would allow Anthem to contract
with a lab, x-ray facility or any other type of facility - example, EEGs or EKGs -
in any part of the country or in any other part of New England. The specific language in
the clause provided that specific "services shall be provided exclusively by
designated Network providers" even "if a provider typically could have performed
such services in their office." This means that the physician would still not be
allowed to perform that procedure or do that test for the patient in their own office even
if they have the equipment and training. They had to have the patient leave the office,
have the test done and then return later to discuss the results. This is not good for
patients. In addition we felt that this was not appropriate to require New Hampshire
patients, who could be treated by New Hampshire physicians, to have their lab work or any
of these tests done by non-New Hampshire licensed physicians in another state or even out
of our region. The direct physician to physician dialogue is often critical in
decision-making for patients. Based on this regionalization concept, we became concerned
that some of these contract clauses would disempower and potentially harm New Hampshire
patients and make it very difficult to check and confirm test results.
Q: Do you have any other thoughts regarding Anthems plan to regionalize its
services in New England?
A: Well, I think its important as we look to having Anthem taking over each
individual states Blue Cross Blue Shield plan that we understand that since New
Hampshire went through this process, the market in New England has changed dramatically
and the market in New Hampshire has changed dramatically. We are now down to two insurers
of substance in New Hampshire, one of them being Anthem. If Anthem does become a New
England regional program, each individual state within that regional program will become a
very small cog in a much larger wheel. The New England region itself will be a relatively
small cog in an even larger national wheel. So we have to question, as we look at this
issue of whether we turn our Blue Cross Blue Shields from not-for-profit to
for-profit companies, whether we are going to entirely lose our local input and control as
these plans grow into larger and larger regional and national plans. The physicians of New
Hampshire have expressed great concern to me about the concept that as we perhaps
regionalize or perhaps become part of a bigger family, that we will have very little say
in how insurance is offered in our state and how we practice medicine in our own state.
Q: Does this conclude your prefiled testimony?
A: Yes. I would be happy to respond to any questions.
Georgia A. Tuttle, M.D.
Michel A. LaFond
Sulloway & Hollis, P.L.L.C.
The undersigned hereby certifies that on March 28, 2000 a copy of the Prefiled
Testimony of Georgia A. Tuttle, M.D. was served via United States mail, first class
postage prepaid, on each of the persons listed below.
Gordon H. Smith