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1. County-Organized Health Systems Are NOT
Exempt from Federal Security Prescription Law
As reported last week in CMA Alert, prescriptions paid for by Medi-Cal managed care plans are exempt from the new federal security prescription rules that take effect next week.*** We have just learned, however, that with the exception of the Health Plan of San Mateo, drugs dispensed within a County-Organized Health System are defined under the law as “covered outpatient drugs” and must be written on tamper-resistant prescription pads. Therefore, prescriptions for patients enrolled in CalOPTIMA, Santa Barbara Health Initiative, Partnership Health Plans, and Central Coast Alliance for Health must be written on tamper-proof pads.
Also exempt from the new federal law are nursing homes and some other institutional settings and phoned, faxed, or electronically transmitted prescriptions. Of course, all prescriptions for controlled substances, regardless of the payor, must be written on secure tamper-proof pads under California Law.
There has also been confusion about dual-eligible (Medicare/Medi-Cal) patients. If the drugs being prescribed are covered by Medicare Part D, then physicians do not need to write the prescriptions on secure pads. However, if the drugs are not covered by Part D, physicians do need to use a secure pad. Of course, if patients are enrolled in a managed care plan or are in an institutional setting, they are exempt from the law and physicians do not need to use a secure pad.
Recognizing that this new law is very confusing, and physicians may not be able to easily determine when Medi-Cal fee-for-service is the secondary payor to private insurance, or if a prescribed drug is carved out of managed care, the California Department of Health Services is recommending that prescribers use tamper-proof prescription pads for all Medi-Cal beneficiaries.
CMA is extremely concerned that confusion among physicians and pharmacists will negatively impact patient care and access to prescription drugs. We are also concerned that the additional hassle and cost involved will force physicians to leave the Medi-Cal program, where access to care is already a problem. CMA is working on federal urgency legislation to reverse the law or at least make it consistent with current state law.
To help ease the burden of this new requirement, especially for physicians with a high volume of Medi-Cal patients, CMA has negotiated a 20 percent member discount on tamper-proof pads and printer paper that meet both federal and state security prescription requirements.
This special discount from CMA’s security prescription partner RxSecurity is available through Wednesday, November 7. After that date, members will receive the normal member discount of 15 percent.
***At press time, the U.S. House of Representatives had passed a bill that would postpone the implentation of the new security prescription rules for 6 months. The Senate is expected to vote on the bill by the end of the week.
Click here for more information.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
2. Blue Cross Underpaid Doctors for HPV Vaccine;
Insurer to Reprocess Claims
CMA recently learned that Blue Cross underpaid physicians for some claims for the HPV vaccine Gardasil. The insurer has informed CMA that it will automatically reprocess affected claims and expects the readjudication process to be completed by the end of October.
According to Blue Cross, nearly 1,000 providers were impacted by this error, which was corrected on June 21. Claims paid after that date were paid at the correct rates.
Contact: Desiree Rice, 916/551-2865 or drice@cmanet.org.
3. How to Avoid NPI-Related Medicare Claim Rejections
As you likely know, California’s Medicare carrier NHIC has begun rejecting claims if it is unable to match a physician’s legacy identifier (PIN) to his or her National Provider Identifier (NPI). Particularly affected by this are solo incorporated practitioners who have both individual (entity type 1) and organization (entity type 2) NPIs.
Physicians using both legacy (PIN) and NPI numbers on their claims must make sure the provider types match. If using an individual NPI, you must also use an individual PIN (and vice versa). Pairing your corporation’s NPI with your individual PIN or your individual NPI with your corporation’s PIN will cause your claims to be rejected.
It is possible that physicians experiencing NPI-related claim rejections will have to complete a new Medicare enrollment form. Changes in the enrollment process over the years have caused some differences between the NPI and Medicare identification number assignment process. This may require some physicians to reenroll so that their NPI and Medicare “provider types” match.
Physicians experiencing NPI-related rejections can submit claims using their legacy PIN only. Be aware, however, that Medicare may at any time choose to stop accepting claims with legacy numbers. Physicians with NPI problems should contact NHIC immediately so the problem can be identified and solved. For NPI-related questions, call NHIC at 877/527-6613.
Click here for more information, including guidance on this issue from NHIC and the Centers for Medicare & Medicaid Services.
Contact: Frank Navarro, 888/401-5911 or fnavarro@cmanet.org.
4. CMA Opposes Standardized Patient Waiting Times;
Urges DMHC to Enforce Current Regulations Requiring
Adequate Provider Networks
The Department of Managed Health Care (DMHC) recently proposed regulations that would require physicians to see patients covered by DMHC-regulated health plans within certain prescribed time frames. The regulations would, among other things, require a primary care physician to see patients with urgent health care needs within 24 hours, to see those with routine health care needs within eight business days, or to refer patients to specialists for urgent care within 72 hours.
CMA is concerned that the proposed regulations are inconsistent with the legislative intent of the Knox-Keene Act. In passing the act in 1975, the Legislature found that “lack of timely access to health care may be an indicator of other systemic problems such as lack of adequate provider panels, fiscal distress of a health care service plan or health care provider, or shifts in the health needs of a covered population.”
The Knox-Keene Act already contains numerous requirements for patient access. “Enforcement of these laws is the first step toward achieving access to care by ensuring that sufficient numbers of physicians are able and willing to participate with health plans so that patients can obtain medically necessary services,” wrote CMA’s Aileen E. Wetzel in comments submitted to DMHC last week.
CMA urged DMHC to focus its efforts on collecting detailed information from health plans to ensure that they have adequate networks of contracting providers, instead of implementing burdensome regulations.
Click here for more information, including a copy of CMA’s comments
Contact: Aileen E. Wetzel, 888/401-5911 or awetzel@cmanet.org.
5. U.S. House Passes Bill to Expand Children’s
Health Insurance Program
The U.S. House of Representatives on Tuesday approved a bill that would expand the State Children’s Health Insurance Program (SCHIP) to cover 10 million poor children at a cost of $35 billion over five years. The expansion would be financed by a 61-cent increase in the federal tobacco tax.
The program, which currently provides insurance for 1.1 million children in California and 6.6 million nationwide, expires next week. If the program isn’t extended, millions of children could – at least temporarily – lose their health insurance.
The Senate is expected to vote on the compromise bill by the end of the week. President Bush has threatened to veto this legislation.
The U.S. House earlier this month passed a bill that would have not only reauthorized the SCHIP program, but also stopped the 15 percent physician pay cut. Additionally, it would have updated California’s geographic payment localities and prevented any geographic payment reductions for three years. The Senate, however, passed a scaled-down version of the House bill, without the Medicare provisions.
CMA will continue to work with congressional leaders to stop the impending payment cuts before they take effect January 1. Senate leadership has committed to adopt Medicare physician payment reform legislation before the end of the year.
Click here for more information.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
6. Member Benefit of the Week: IC System Collection Solutions
For more than 20 years, CMA has partnered with I.C. System to help physicians improve their cash flow with efficient, ethical, and cost-effective debt collection solutions.
I.C. System, one of the nation’s largest privately owned collection agencies, employs experienced health care industry professionals who thoroughly understand patient accounting. The personnel at I.C. System receive specialized training to maximize recoveries while maintaining positive patient relationships.
I.C. System also offers an insurance resolution package and recently launched an online tool that allows practices to find current addresses and/or phone numbers for returned/undeliverable invoices.
CMA members receive a 10 percent “bonus” on all I.C. System products and services. For example, if you sign up for a 75-account package, you get to submit up to 83 accounts at no extra charge.
Since 1985, CMA members have recovered more than $22.6 million with the help of I.C. System. For a no-obligation quote, contact I.C. System at 800/279-3511 and make it clear that you are a CMA member.
Click here for more information on your membership benefits.
Contact: CMA's membership hotline, 800/786-4CMA (4262) or lgodward@cmanet.org.
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No. 2111
