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1. Aetna Agrees to Pay Physicians for Denied Add-On Code Claims for CAD Mammography and Myocardial Perfusion Testing Retroactive to 2004
In a significant victory for physicians, Aetna and representatives of various state medical societies have settled a dispute about the payment of certain so-called add-on codes, which are claims submitted for additional procedures by the same physician above and beyond the primary procedure. Aetna has agreed that it will retroactively pay claims with add-on codes for computer-aided digital (CAD) mammography and myocardial perfusion testing with dates of service on or after January 1, 2004.
The additional payments—both retroactive and ongoing—provide a substantial financial benefit for thousands of physicians nationwide.
When Aetna in May 2003 settled CMA’s RICO lawsuit, the health plan agreed to make numerous changes to its payment policies to make them more consistent with CPT coding guidelines. One such change was to pay all add-on codes from the date they became effective under CPT. The settlement language requires that “ ‘add-on’ codes, as designated by CPT, shall be recognized and eligible for payment as separate codes and shall not be subject to multiple procedure logic.”
Aetna did not, however, recognize codes for CAD mammography (CPT codes 76082 and 76083) and myocardial perfusion testing (CPT codes 78478 and 78480), and these claims were denied. Some physicians stopped filing claims for those services, after it became apparent that Aetna would not pay for them. A number of physicians filed RICO settlement compliance disputes regarding the denials of these codes and last year Aetna did begin paying for these add-on codes (effective April 1, 2005, for CAD mammography, and May 12, 2005, for myocardial perfusion testing).
CMA and representatives from other state medical societies continued to push Aetna to retroactively pay such claims. Thanks to tireless CMA advocacy, Aetna this week agreed to allow physicians to resubmit previously denied claims and to submit new claims with add-on codes for CAD mammography (with dates of service between January 1, 2004, and April 1, 2005) and myocardial perfusion testing (with dates of service between January 1, 2004, and May 12, 2005).
Physicians can begin submitting or resubmitting these on April 17. Instructions for resubmitting previously denied claims will soon be posted at Aetna’s provider website,
http://www.aetna.com/provider. (Click on “Add-On Code Claims Payment,” which will be under “Features” in the lower right-hand corner.) New claims should be submitted following standard billing procedures. Both new and resubmitted claims must be filed no later than July 14. Practices may submit claims on behalf of physicians who worked for the practice when the service was provided, even if they are no longer employed there.
Physicians can call Aetna’s provider service center for more details (888/632-3862 for PPO plans or 800/624-0756 for HMO plans).
Click here for more information on CMA’s RICO lawsuit and settlement enforcement activities.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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2. Quality Matters: Open-Source Medical Journal Helps
Physicians Translate Clinical Research into Practice
The Internet is awash with medical information. But the most reliable medical information on the web—the contents of peer-reviewed medical journals—is hidden from the public and most of the world’s physicians. Although most medical journals are available online, their publishers limit access to those who choose, and can afford, to pay for access.
Unlike traditional medical journals, which limit access to maximize subscription revenue, the Public Library of Science’s journal PLoS Medicine is a free, open-source, peer-reviewed medical journal. The journal, launched in October 2004, is an international, multidisciplinary medical journal. It publishes studies designed to enhance the understanding of human health and disease and help physicians translate clinical research findings into clinical practice.
Because PLoS believes that medical research is an international public resource, its articles can be downloaded and distributed without restriction as long as the author is given proper credit. Publishing costs are offset by a publication fee charged to authors. PLoS waives the fee for authors with insufficient funds. The ability to pay is not known by the editors, and never affects the decision whether to publish an article.
PLoS was cofounded by Harold Varmus, M.D., former director of the National Institutes of Health (NIH) and corecipient of a Nobel prize for his research in cancer genetics; Patrick Brown, M.D., professor of biochemistry at Stanford University School of Medicine; and Michael Eisen, a computational and evolutionary biologist at Lawrence Berkeley National Laboratory.
PLoS Medicine can be found online at
http://www.plosmedicine.org.
Click here for previous issues of "Quality Matters."
Quality Matters is a monthly feature that focuses on practical ways physicians can improve the quality of the care they provide to their patients. Quality Matters is published in CMA Alert and at the California Physician website the second Thursday of every month.
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3. Analysis of New PacifiCare Contract Available Free to Members
As recently reported in CMA Alert, CMA has received a number of calls from physicians concerned about the new PacifiCare/United Healthcare contract. CMA has analyzed the PacifiCare contract and found that it in many ways violates the Knox-Keene Act.
CMA reported its finding to the Department of Managed Health Care (DMHC), and the department has given PacifiCare 10 days to modify the contract so that it complies with Knox-Keene and other regulations.
A detailed analysis of the contract, and its flaws, is available to members at the members-only website. Click on “Reimbursement Advocacy” under “Physician Advocacy” in the main menu. There you will also find objective written analyses of a dozen other major health plan contracts.
CMA reminds physicians that before signing a health plan contract, it is important to know what value that relationship will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial.
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.” The toolkit is available free to members at the CMA website. Nonmembers can purchase the toolkit for $100.
Click here for more information.
Contact: Aileen Wetzel, 916/444-5532 or awetzel@cmanet.org.
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4. CMA Receives National Award for Media Relations in Schiavo Case
CMA this week received a national Bulldog Award for excellence in media relations for work by its Communication Center during the Terri Schaivo case. CMA’s entry, “Helping Doctors Help Patients – the Terri Schiavo Case Has a Silver Lining,” received the bronze award in the not-for-profit/association/government category.
In March 2005, the nation’s attention was fixed on a nursing center in Florida, where Terri Schiavo had lived for years in a persistent vegetative state, despite her husband’s efforts to disconnect her feeding tube. The Schiavo case underscored the importance of putting in writing your wishes about end-of-life care. CMA has long championed advance care directives and CMA seized the opportunity to encourage dialogue about this important and difficult issue.
Then, as the CMA House of Delegates (HOD) met that March, Congress and President Bush involved themselves in the case. The HOD reacted by passing an emergency resolution condemning congressional interference in efforts to remove Schiavo’s feeding tube. The award recognized the communication team’s proactive publicity on end-of-life care, as well as its swift reaction to the emergency resolution, which received national attention. Not content to stop there, CMA also created a Public Service Announcement on end-of-life care, which was broadcast by TV stations across the state.
CMA’s involvement in this volatile issue prompted both praise and criticism, but ultimately resulted in tens of thousands more people putting their health care wishes in writing.
Click here for more information.
Contact: Karen Nikos, 916/551-2069 or knikos@cmanet.org.
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5. Spread the Word: PBS Program on Part D to Air this Month
This month, PBS stations in California will be airing a 30-minute program about the Medicare prescription drug benefit, “Medicare Forum: Making Sense of Part D.” As the May 15 enrollment deadline approaches, millions of patients remain confused about the Medicare prescription drug benefit.
This program will help beneficiaries understand how Part D coverage works and how to select the best plan for their particular needs. Under the law, eligible patients who do not sign up by the deadline will face a 1 percent per month premium penalty for the duration of the program.
To help physicians get the word out about this helpful and informative program, CMA has posted on its website a flyer you can photocopy and make available to your patients.
Click here for more information.
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6. PrivaPlan Publishes National Provider Identifier Toolkit
Next year, physicians will no longer have to keep track of and use multiple identification numbers assigned to them by health plans. Effective May 23, 2007, physicians will instead use a single “national provider identifier” (NPI).
The HIPAA-mandated national provider identification system promises to simplify electronic health care transactions and create a more easily accessible database of provider information for credentialing and contracting purposes.
NPIs will, however, pose a unique challenge to your software systems, including billing and electronic health records. Will your software systems be current with the new number when it is required? Physicians are advised to start an inventory as soon as it is practical.
CMA’s HIPAA partner, PrivaPlan Associates Inc., has developed an inexpensive CD-ROM toolkit to help physicians navigate the NPI process. CMA members pay $99. CMA members who have purchased PrivaPlan’s other HIPAA toolkits pay $79. Nonmember pay $129. Order the toolkit by calling 877/218-7707.
More information on NPIs is available in CMA ON-CALL document #1608, “National Provider Identification Numbers.” ON-CALL documents are free to members at CMA’s members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in CMA’s online bookstore.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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7. Save the Date: A Midsummer Night’s Wheeze,
July 21-23 in Huntington Beach
CMA has endorsed the California Society of Allergy, Asthma and Immunology conference, “A Midsummer Night’s Wheeze.” The three-day program is July 21-23 at the Hilton Waterfront Beach Hotel and Resort in Huntington Beach.
Attendees will have the opportunity to improve their understanding of the pathophysiology and treatment of allergic and immunologic disorders. Presented by nationally recognized speakers, the conference will explore:
- New information pertaining to the natural history and pathogenesis of allergic skin, ocular, and respiratory diseases
- Current therapeutic strategies and the ability to control allergic diseases
- Developments in the pathogenesis, evaluation, and treatment options of immune deficiency states
- Complementary and alternative medicine treatments options in asthma, allergic diseases, and immunologic disorders
- Developments in the pathophysiology, morbidity, and treatment of obstructive sleep apnea and the relationship to allergic disorders
CMA members pay $160, nonmembers $250. Participants can receive 12 hours of Category I CME.
Click here for more information.
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8. Did You Know?
Did you know that in 1935, at the height of the Depression, CMA spent $50,000 (nearly $700,000 in today’s dollars) to study health care for the poor and also sponsored state legislation, Senate Bill 454, to require health insurance for all California citizens? Although the bill didn’t pass, it had significant support. That year, CMA membership reached an all-time high (to that point) of 5,000 members. CMA’s efforts drew sharp criticism from the AMA, which opposed all insurance.
CMA is celebrating its 150th birthday! Visit http://www.cmanet.org/150 for other interesting information about CMA history.
Contact: Karen Nikos, 916/444-5532 or knikos@cmanet.org.
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9. CMA Member Benefit of the Week: CME and Conference Discounts
Members can save big on conferences sponsored and endorsed by CMA. For example, members get $300 off CMA’s Health Care Leadership Academy (May 5-7 in Indian Wells); $210 off Decision Health’s pay-for-performance summit (May 18-19 in Las Vegas), and $260 off Pain, Palliation, & Politics, CMA’s pain management and end-of-life CME program (September 8-9 in San Francisco, and December 1-2 in Anaheim).
Click here for more information about the benefits and discounts available to CMA members.
Contact: CMA's membership help line, 888/233-2937 or lgodward@cmanet.org.
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No. 2047 
