1. United Healthcare Eliminates “Progressive Fee Schedule”
In response to CMA advocacy, United Healthcare has agreed to stop using its “progressive fee schedule” methodology, which CMA believes to be a violation of state fair payment laws. Currently, United makes significant changes to its fee schedules under the guise of “routine maintenance,” without notifying physicians or giving them the opportunity to cancel their contracts. Last year, CMA asked the Department of Insurance to force United to comply with state law, which requires insurance companies to give contracted physicians 45 days notice of any material changes to their contracts.
United’s progressive fee schedules are developed using third party data (such as Medicare’s relative value units). According to United, “routine maintenance” occurs when it “mechanically incorporates revised information created by a third party that is the source for a portion of the fee schedule.” Physicians have reported to CMA that payments for some CPT codes have been reduced by as much as 10 percent during such “routine maintenance.” These fluctuations make it difficult for physicians to predict the exact amount they will be paid.
Over 50 percent of physicians contracted with United Healthcare in California – approximately 25,000 physicians – are on these so-called progressive fee schedules. Affected physicians were recently notified by certified mail of United’s decision to eliminate the progressive fee schedule. Effective April 1, the fee schedule will be fixed to 2008 CMS RBRVS. (Physicians will see no difference in their current reimbursement.) Included with the notice was a sample fee schedule.
CMA reminds physicians that before signing a health plan contract or contract amendment, it is important to know what value it will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial. If you do not agree with the proposed change, you may terminate your contract by notifying United in writing prior to the April 1 effective date.
To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting.” This toolkit is available free to members at the members-only website. Nonmembers can purchase the toolkit for $100 in the CMA bookstore.
Questions about the new fee schedule can be directed to United Healthcare Provider Services at 888/291-0404.
Click here for more information.
Contact: Aileen E. Weztel, 916/551-2037 or awetzel@cmanet.org.
2. Medi-Cal Claims with Patient SSNs Will Be Denied Beginning 2/1
Beginning on February 1, physicians can no longer bill Medi-Cal or the Child Health and Disability Prevention Program using patients’ Social Security numbers as identifiers. All providers must use the 14-character Medi-Cal identification number from recipients’ Benefits Identification Cards (BIC) or paper ID cards when submitting claims. The ID number is located on the front of the card and consists of a 9-digit client index number, a check digit, and a 4-digit issue date. (The issue date is used to deactivate cards that have been reported as lost or stolen.)
The only exemption to this rule is for Medicare crossover claims. Physicians may continue to bill Medicare crossover claims using the recipient’s SSN/Medicare number as it appears on beneficiaries’ Medicare identification cards.
Physicians are also urged to use Medi-Cal identification numbers when verifying eligibility or submitting treatment authorization requests. In an emergency or in the event a Medi-Cal patient does not bring his or her BIC to an appointment, physicians may (with the patient’s permission) use a SSN to verify eligibility via the Medi-Cal Eligibility Verification System.
This rule, originally scheduled to take effect last year, was postponed to allow DHS time to educate providers and patients about this policy change. Notices were mailed to all beneficiaries reminding them of the importance of taking their BIC with them to the doctor, pharmacy, or hospital. The notice also warned patients that they may not be able to see their doctor or fill a prescription without their BIC because providers need that information to bill Medi-Cal.
Click here for more information.
Contact: Frank Navarro, 916/551-2046 or fnavarro@cmanet.org.
3. HHS Extends ICD-10 Deadline to 2013; CMA, AMA Continue
to Advocate for an Eight Year Transition Plan
The U.S. Department of Health and Human Services (HHS) recently announced plans to replace the ICD-9-CM code sets now used to report health care diagnoses and procedures with greatly expanded ICD-10 code sets, effective Oct. 1, 2013 – two years later than originally planned.
Despite this two-year delay, CMA, AMA, and others in organized medicine remain deeply concerned that the 2013 compliance deadline proposed by HHS will not provide adequate time for a smooth transition from ICD-9 to ICD-10. CMA has urged HHS to reconsider its proposed timeline, as moving from ICD-9 to ICD-10 will be a significant change for the health care community. A transition of this magnitude will require a workable implementation process and realistic timeline for all HIPAA covered entities, and comprehensive outreach and education initiatives to support health care providers, especially small physician practices, throughout this complex move to ICD-10. CMA and AMA have proposed an 8-year transition plan.
Developed almost 30 years ago, ICD-9 is now widely viewed as outdated because of its limited ability to accommodate new procedures and diagnoses. ICD-9 contains only 17,000 codes and is expected to start running out of available codes next year. The ICD-10 code sets—which are already used in other countries and by the World Health Organization—contain more than 155,000 codes and can accommodate a host of new diagnoses and procedures.
Click here for more information.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
4. Palmetto Agrees to Eliminate Monitored Anesthesia Policy
Thanks to CMA advocacy, Palmetto GBA – California’s Medicare Carrier – has agreed to repeal the overly restrictive “monitored anesthesia care” policy. Under the policy, which was adopted prior to the transition to Palmetto as the new Medicare carrier in September, monitored sedation by anesthesiologists for many procedures – including cataract surgery and colonoscopies – was only covered for high-risk patients with a demonstrated medical necessity.
The retraction of this policy returns medical decision making power to physicians and surgeons.
Palmetto has also agreed to retroactively reimburse previously denied claims for monitored anesthesia care. It is not yet clear whether claims will be automatically readjudicated, or whether physicians will have to submit appeals.
Stay tuned for more details.
Contact: Frank Navarro, 916/551-2046 or fnavarro@cmanet.org.
5. Despite Escalating Budget Crisis State Will
Not Delay Medi-Cal Payments
In an attempt to manage the escalating budget crisis, the state controller recently announced that he will delay some state payments by 30 days to preserve cash for legally-protected and priority programs, such as Medi-Cal. Absent a state budget fix, the State of California will be $346 million in the red at the end of February, $5.2 billion by April, and $10 billion by July.
The state will continue to pay for Medi-Cal services with available cash. However, as the state’s coffers are further depleted, the controller may have to begin delaying Medi-Cal payments or issuing IOUs. The controller has no plans to do so at this time, but we will keep you informed of any further developments.
Click here for more information.
Contact: Lisa Folberg, 916/444-5532 or lfolberg@cmanet.org.
6. House Passes Children’s Health Insurance Bill;
Senate Expected to Follow
The U. S. House of Representatives recently voted 289 to 139 to reauthorize and expand the federal State Children’s Health Insurance Program (SCHIP) for five years. This extremely successful program currently provides affordable health coverage for more than 900,000 California children (and 6.6 million children nationwide). The Senate is expected to vote on the bill this week.
The House-approved bill, which is nearly identical to the one-year extension passed by Congress last year, is funded with a 61-cent cigarette tax and savings from a ban on new physician-owned specialty hospitals. One major difference, however, is that the bill waives the 5 year waiting period for legal immigrant children and pregnant women. California currently covers them with state-only money.
Although CMA strongly supports the goals of this bill, it opposes the physician-owned hospital ban. The Senate version of the bill does not include a such a a ban.
President Obama has also indicated that he will rescind a Bush administration policy that has impeded state efforts to provide health insurance to children from low- and middle-income families. Under the Bush policy, states were not allowed to cover children from families with annual incomes above 250 percent of the poverty level — $53,000 for a family of four — unless 95 percent of eligible children in families making less than 200 percent of the poverty level were already been enrolled in Medicaid or SCHIP. This nearly impossible standard has blocked or delayed the expansion of coverage in several states.
CMA has been active in the fight to support Healthy Families at the state and national levels. This program is even more critical in these tough economic times. Due to the national economic recession, 1.2 million children have lost employer-sponsored insurance in the past year alone. California’s Healthy Families program has been enrolling over 27,000 new eligible children each month, the highest level in its history.
Click here for more information.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
7. CMA Launches Webinar Series
CMA is excited to announce that we will hosting a series of live monthly webinars to educate physicians on a range of topics from health information technologies to reimbursement issues.
The first webinar on e-prescribing will be Monday, February 9 (8 - 8:30 pm), presented by Maxwell IT. On Tuesday, February 24 (12:30 - 1:15 pm), CMA’s Director of Litigation will present recent developments in the fight to ensure fair payment for out-of-network emergency services and discuss physicians’ options.
To register or view a full list of currently scheduled webinars visit http://www.cmanet.org/calendar. Space is limited so register soon.
Contact: Shannon Navarra-Lujan, 800/786-4CMA or slujan@cmanet.org.
8. Federal Economic Stimulus Plan Contains $150 Billion
for Health Care
The $800+ billion economic stimulus package being crafted by Congress and the Obama Administration will likely contain more than $150 billion for health care, including more than $87 billion in direct funding to states to bolster their Medicaid programs and $30 billion in extended COBRA coverage for recently unemployed workers. California’s Medi-Cal program alone stands to gain more than $7 billion under the proposal currently working its way through the House of Representatives.
Highlights of the current package include:
- $20 billion for health care information technology (HIT), including $50,000 over 5 years for every physician to help offset the cost of purchasing and implementing HIT systems. To be eligible for the HIT funds, physicians would be required to participate a confidential quality reporting program.
- $87 billion for increased Medicaid funding to states, largely through an increase in the federal match.
- $3 billion for a prevention and wellness fund, which will provide grants for state and local public health departments, immunization programs, and evidence-based disease prevention programs.
- $600 million to address provider shortages, including funds for training primary care providers and help for medical students who agree to practice in underserved communities.
The stimulus package also includes funding for community clinics, biomedical research, and studies on the efficacy of treatments funded by the federal government. Overall, the health care elements of the stimulus package reflect the Administration’s belief that technology and research can lower health care costs and improve the quality of medical care.
CMA continues to work closely with members of Congress and the Administration to ensure the voices of physicians and patients are heard and considered as new health care policies are developed.
President Obama has indicated that he expects the economic stimulus package to be passed by February 16.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
9. Call for Data: Out-of-Network Underpayment and Rescission of Treatment Authorization
CMA and specialty physician associations have prepared a survey to gauge the impact on physicians and their patients of the recent balance billing regulation and the Prospect ruling that prohibits “balance billing” patients for the unpaid portion of bills only partially paid by Knox Keene plans for noncontracted emergency services. CMA is also gathering evidence concerning other, broader industry practices by health insurers to underpay for out-of-network services (e.g., by use of the Ingenix database).
We understand that completing this survey takes time, but the data gathered will play an invaluable role in our advocacy efforts. Data will not be used in a manner that reveals your identity.
The survey is available online. You may also request a paper copy by calling 916/551-2872.
Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.
10. Benefit of the Week: Employment Practices Liability Insurance
Through CMA’s group buying power, members receive significant premium discounts employment practices liability (EPL) insurance from Marsh. And with a special first-time buyers program, applying is easier than ever.
EPL insurance provides critical protection against claims of wrongful termination, harassment, and discrimination made by employees or patients.
The CMA-endorsed EPL insurance program also provides important preventive tools including web-based risk management training and an 800 number for access to labor attorneys. Limits of $250,000, $500,000 or $1,000,000 are available, with low annual premiums beginning at $750 ($1,000 in Los Angeles County).
Call a Marsh at 800/842-3761 for more information.
Click here for more information on your membership benefits.
Contact: CMA’s member help line, 800/786-4CMA or twilson@cmanet.org.
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