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1. Blue Cross’s New Payment Policies Violate Prompt Pay Law
Blue Cross-contracted physicians were recently notified of significant changes to the plan’s medical and reimbursement policies. CMA believes some of the new policies to be in violation of California’s unfair payment practices legislation (AB 1455) and has reported its concerns to the Department of Managed Health Care.
CMA is specifically concerned with Blue Cross’s expanded list of medical policies subject to 100 percent post-service review. Typically, during post-service review, the payor generates a request for medical records. These requests for records generally occur weeks after the initial receipt of the claim. Such reviews create an additional hassle of providing documentation, can significantly delay payment beyond the time frames allowed by law (30 days for PPOs and 45 days for HMOs), and can create a real financial hardship for practices.
Physicians have two options that may prevent this delay. In its communications to the Department of Managed Health Care, Blue Cross has stated that it will accept medical records when submitted with the initial claim. Providing documentation at the time of claim submission can speed up payment for services subject to a mandatory post-service review. However, best practice would be to obtain prior authorization for requested service, even if none is required. According to the DMHC, Blue Cross has indicated it will provide a prior authorization upon request, for these newly listed services.
California’s CMA-sponsored prompt-pay law (AB 1455) prohibits Knox-Keene plans and insurance companies from rescinding or modifying an authorization after the physician performs the service in good faith. This means that once an authorization been given, the physician is guaranteed payment. (For more information, see CMA ON-CALL document #0145, “Payment Denial After Treatment Authorization or Verification of Eligibility.”)
Physicians should also be aware that under most circumstances, Blue Cross will deny payment for procedures deemed “investigational” or “not medically necessary.” In addition, the Blue Cross contract prohibits billing the patient for a claim that has been denied as not medically necessary/investigational.
Click here for more information, including a copy of the Blue Cross notice and the expanded list of procedures subject to post-service review.
Contact: CMA’s reimbursement help line, 888/401-5911.
2. CMA Commends Governor’s Efforts to Expand Health Care, But Objects
to 2% Tax on Physicians; Policy-Makers Reminded that Focus Must Be on Preserving Patient-Physician Relationship
Governor Schwarzenegger Friday unveiled a plan to provide health care to all Californians. The proposal would expand Medi-Cal and Healthy Families programs and require all Californians to have health insurance. Families above the Medi-Cal threshold, but with incomes below 250 percent of the federal poverty level ($41,500 for a family of three), would be able to purchase insurance from a subsidized purchasing pool. The proposal would also require employers to offer insurance or pay 4 percent of their payroll into the purchasing pool.
CMA applauds the governor for addressing the long-ignored health care policies of this state, but urges policy-makers to remember that the center of the health care system is patients and their ability to see and be treated by a doctor.
“Health care is the interaction between patients and their doctors – everything else is just the where, how, and when,” says CMA President Anmol S. Mahal, M.D. “Preserving and enhancing the ability of patients to see a medical doctor and be treated is central to any policy prescription our elected leaders consider in the coming months.”
CMA is concerned that the governor’s proposal is not adequately funded and relies on funds from inappropriate sources.
The $12 billion proposal would be paid for in part by a 2 percent “provider tax” on health care services. CMA believes that taxing physicians and hospitals only penalizes the very people and entities already providing care often for free or below the cost of care.
The governor’s proposal would also expand the scope of practice of medical practitioners, including nurse practitioners and physician’s assistants, such that they could practice without physician supervision. CMA is concerned that eliminating physician supervision of medical practitioners would jeopardize patient safety.
Acknowledging that Medi-Cal rates are unsustainably low, the proposal includes a significant increase to Medi-Cal rates. However, the increases would be tied to participation in a new and unspecified pay-for-performance program and adoption of health care information technology, such as electronic medical records.
CMA will work closely with the Schwarzenegger administration to ensure that any plan to reform health care does not jeopardize the viability of an already fragile health care delivery system. All policy proposals need careful consideration based on a central question, says Dr. Mahal. “How can we assure that the sick, suffering and infirm are able to see a doctor when they need to?”
More than 100 medical students and resident and young physicians from across the state gathered in Sacramento Tuesday to deliver this message to lawmakers. White coats blanketed the halls of the Capitol as materials were delivered to each member of the Senate and Assembly prior to the governor’s State of the State address.
Click here for more information, including a summary of the governor’s proposal.
Contact: Susan Bassett, 916/444-5532 or sbassett@cmanet.org.
3. CMA Summary of Governor's Proposed 2007-2008 Budget Available
The Schwarzenegger administration yesterday released its proposed 2007-2008 budget. A summary of the budget as it relates to health care is available here. More details on the Governor's proposed budget will be published in next week's CMA Alert.
Click here to view the budget summary.
Contact: Lisa Folberg, 916/444-5532 or lfolberg@cmanet.org.
4. Payors Respond to CMA's NPI-Readiness Survey
In four months, physicians will be required to use their new National Provider Identifiers (NPI) on claims and other electronic health care transactions. NPIs will replace UPINs and other payor-specific provider identification numbers.
CMA recently surveyed major California payors to assess their NPI readiness. The results of the survey are available to members at the members-only website.
CMA would like to thank the payors who have participated to date, Aetna, United Healthcare/PacifiCare, and Blue Shield.
Don't forget, the deadline to submit your NPI to Medi-Cal is March 1. Click here for more information on obtaining an NPI. Click here for more information on obtaining an NPI.
Contact: CMA’s reimbursement help line, 888/401-5911.
5. NHIC Hosting NPI Teleconference
NHIC, California’s Medicare carrier, is hosting a free one-hour teleconference for Medicare Part B providers on the topic of National Provider Identifiers.The teleconference is Thursday, February 8, at 10 a.m. Pacific time. Physicians and their staff are invited to participate.
Registration is not required, but the number of call-in lines is limited. Dial in early to secure your spot on the call.
Call 888/469-0487 and enter pass code “NPI.”
Don't forget, the deadline to submit your NPI to Medi-Cal is March 1. Click here for more information on obtaining an NPI.
6. Deadline to Opt Out of Blue Cross Workers’ Comp Networks Is January 21
Physicians should be aware that even though Blue Cross has an “all products” clause in its Prudent Buyer contract, the plan agreed as part of its RICO settlement with CMA that it would not require physicians to participate in its Workers’ Compensation networks. Physicians who do not wish to participate in these networks can opt out by notifying Blue Cross in writing by January 21. Physicians who opt out will still be free to negotiate separate contracts with Blue Cross to provide workers’ comp services.
Even though providers are required to give notice by January 21, 2007, that election will not become effective until January 21, 2008. Until then, all Prudent Buyer providers will continue to be obligated by their Prudent Buyer contracts to treat Blue Cross patients with work-related injuries and illnesses.
This opt-out right does not apply to physicians or physician groups who have any contract other than the standard Prudent Buyer contract, or an addendum to the standard contract that is specifically related to the provision of medical services for work-related injuries and illnesses.
Newly contracting physicians and groups will be given the opportunity to opt out of Blue Cross’s Workers’ Comp networks at the time the contract is executed.
Blue Cross also confirmed in the RICO settlement that physicians with Prudent Buyer contracts who participate in other workers’ comp networks (MPNs) can provide services to injured workers under the other MPN contracts and are not required to refer those patients to Blue Cross participating physicians.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
7. Medicare Extends Participation Decision Deadline to Feb.14
The Centers for Medicare & Medicaid Services (CMS) has extended the Medicare participation enrollment period. Physicians who wish to change their Medicare participation status for 2007 have until February 14 to do so. Changes in participation status will be effective January 1, retroactively if necessary, regardless of when the participation decision is made.
Click here for more information.
Contact: CMA's reimbursement help line, 888/401-4911.
8. CMA Hosts Payor Contracting Seminars for Physicians and Their Office Staff
CMA and county medical societies are cohosting a series of seminars to help physician practices assess payor contracts and prepare for contract negotiations. The next “Taking Charge” seminar is February 8, in Riverside.
Currently scheduled seminars:
- Feb 8, Riverside
- Feb 21, San Diego
- Feb 27, San Ramon
- March 15, San Mateo
- March 31, San Diego, during the CMGMA Annual Conference
- May 2, Oxnard, during PAHCOM Annual Conference
- April 14 and 15, Monterey, during CMA’s Annual Leadership Conference
Attendees will learn how to:
- evaluate current and proposed payor contracts
- target payors for contract termination, negotiation, or renegotiation
- monitor payor compliance with contract terms
- determine a payor’s value to their practice
- and more!
Participants will also receive a copy of CMA’s payor contracting toolkits (a $125 value), including “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations,” and “Managed Care Contracts Deciphered: The Physicians’ Guide to Their Rights and Obligations.”
Click here for more information, including registration forms and contact information.
Contact: Gabrielle Fonseca, 916/551-2061 or gfonseca@cmanet.org.
9. 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.
CMA members receive a 10 percent “bonus” on all of 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 $22.3 million with the help of I.C. System. For a no-obligation quote, contact I.C. System at 800/279-3511 and specify that you are a CMA member.
Click here for more information on your membership benefits.
Contact: CMA’s membership hotline, 888/233-2937 or lgodward@cmanet.org.
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No. 2077
