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1. CMA Tells DMHC that Blue Cross’s New Payment Rules for Outpatient Endoscopic Procedures Violate Knox-Keene Access-to-Care Requirements
Physicians contracted with Blue Cross of California were recently notified that effective July 1 reimbursement for endoscopic procedures, including colonoscopies, will be cut by 20 percent when such procedures are performed in an outpatient hospital environment. Reimbursement will increase by 5 percent for endoscopic procedures performed in physician offices or in Blue Cross-participating surgery centers. CMA has protested the unilateral change to state authorities, saying the rule places corporate profits ahead of patient care and safety, and is likely illegal. CMA believes that it violates Health & Safety Code §1367(g), which requires that medical decisions be “unhindered by fiscal and administrative management.”
CMA is also concerned that the new policy violates the Knox-Keene access-to-care requirements, as many physicians do not have admitting privileges at Blue Cross-participating surgery centers. Forcing physicians to utilize these surgery centers may also violate the Knox-Keene geographic access rules, which require that covered services be available within 15 miles/30 minutes.
CMA believes the Blue Cross notice violates California’s Provider Bill of Rights, as well. This CMA-sponsored law (AB 1455) requires health plans to give physicians the option to terminate their contract if they do not wish to accept the fee reduction. The Blue Cross notice did not do so.
CMA has reported its findings to the Department of Managed Health Care (DMHC), and the department has given Blue Cross until May 22 to respond to these concerns.
Physicians with specific concerns about patient access or who have difficulty obtaining privileges at a Blue Cross-contracted surgery center can contact Blue Cross’s medical director, Jeff Kamil, M.D., at 818/234-6317 or by mail at 21555 Oxnard Street, AC-6G, Woodland Hills, CA 91367.
Physicians who have been victim of this or other unfair health plan payment practices are encouraged to file a report with DMHC. CMA will certainly continue to advocate on physicians’ behalf, but it is important that DMHC hear individual physician complaints.
Click here for more informaiton.
Contact: Aileen Wetzel, 916/444-5532 or awetzel@cmanet.org.
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2. One Month Left to Get 40% Off Palm Z22 PDA with Epocrates
CMA and the California HealthCare Foundation (CHCF) have collaborated to put easy-to-use technology and valuable information about drug formularies—including Medicare Part D—literally in the palm of physicians’ hands.
For a bundled price of $99, physicians can purchase a Palm Z22 handheld computer and the Epocrates Rx Pro premium software. That’s nearly 40 percent off the regular price. This offer, available to physicians and other clinicians, is only good through the end of May.
With the launch of Medicare Part D in January, Medicare recipients in California now can choose from 48 health plans. The multiple formularies complicate the prescribing challenges facing physicians. These tools will help physicians manage the volume of information needed to pick the correct medicines and provide high-quality care for their patients, especially those with chronic conditions who require multiple medications. Epocrates-enabled handheld computers allow a physician in an exam room to identify which medicines are in which formularies, check for drug interactions, and find drug alternatives.
Click here for more information.
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3. CMA Seeks 15 Percent Increase to Medi-Cal Payment Rates
CMA and a coalition of more than 70 consumer, patient, and provider advocacy groups are seeking a 15 percent Medi-Cal provider rate increase in the 2006-07 state budget. This long-overdue pay raise is critical to preserving and improving access to care for the state’s most vulnerable populations.
The Assembly Budget Subcommittee will hold a hearing on the issue on Monday, May 1. All physicians interested in advocating for the rate increase are encouraged to attend. The hearing begins at 4 p.m. at the State Capitol, room 127. Physicians from Alameda Contra Costa, San Joaquin, Sierra Sacramento, and Yuba-Sutter-Colusa County medical societies have already volunteered to attend the hearing and speak in support of the increase.
There has been just one general Medi-Cal physician rate increase in the last 20 years, and per-patient Medicaid spending by California ranks last among the 50 states. Low Medi-Cal rates already have forced many physicians to stop seeing new Medi-Cal patients or to leave the program completely. More than 60 percent of Medi-Cal recipients report difficulty finding a physician. Many Medi-Cal patients are forced to forgo care or use hospital emergency departments as their primary health care provider, thereby lengthening waits, increasing costs, and decreasing quality of care for everyone.
Click here for more information.
Contact: Susan Bassett, 916/444-5532 or sbassett@cmanet.org.
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4. Physicians DO NOT Have to Participate in
Blue Cross’s Medicare/Medicaid Networks
CMA has received a number of calls from physicians upset that they had been automatically opted into Blue Cross’s Medicare Advantage Regional PPO, Freedom Blue. Physicians should be aware that even though Blue Cross does have 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 Medicare Advantage or Medi-Cal network. Physicians who do not wish to participate in these networks can opt out by notifying Blue Cross in writing.
The all products clause in Blue Cross’s Prudent Buyer contract authorizes the plan to automatically include all contracted physicians in any of its current and future products, including Medicare/Medicaid products. Contracted physicians who treat Freedom Blue patients will be reimbursed at Prudent Buyer rates rather than at Medicare rates.
To opt out, you must notify Blue Cross in writing that you are exercising your rights pursuant to 7.13 (b) of the RICO settlement not to participate in its Medicare and/or Medicaid product networks. More information, including a sample letter you can use to opt out of Blue Cross’s Medicare/Medicaid products, can be found in CMA ON-CALL document #0152, “Medicare Managed Care/Medicare Advantage.” ON-CALL documents are free to members at the members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in the CMA bookstore.
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. Physicians are advised to review payor fee schedules carefully to ensure that the proposed compensation is sufficient to maintain a medical practice.
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 members-only website. Click on “Reimbursement Advocacy” under “Physician Advocacy.”)
Click here for more information.
Contact: CMA’s Reimbursement Helpline, 888/401-5911.
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5. Leadership Academy Approved for 17 Hours of Category 1 CME
There is still time to register for CMA’s 9th Annual California Health Care Leadership Academy, May 5-7 in Indian Wells. Join us at the beautiful Renaissance Esmeralda Resort to acquire practical leadership skills, learn about trends affecting the future of medical practice, and earn 17 hours of very affordable CME credit.
This year’s faculty includes leading health economists, a nationally known political analyst, pioneers of the federal government’s quality and health information technology initiatives, and state and national leaders from virtually every segment of the health care industry. No other conference of this scope and quality offers as much educational content and credit for the price.
CMA members get $300 off conference registration (members pay $695, nonmembers $995). For more information and to register, visit http://www.cmanet.org/leadership or call 800/795-2262.
The California Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. CMA designates this educational activity for a maximum of 17 AMA PRA Category 1 Credit(s)TM. Physicians should only claim credit commensurate with the extent of their participation in the activity. This credit may also be applied to the CMA Certification in Continuing Medical Education. Educational grant support for the 9th Annual Leadership Academy has been provided by Eli Lilly and Company, Procter & Gamble Pharmaceuticals, Genentech, and Johnson & Johnson.
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6.
 150th Anniversary Trivia: Did You Know?
Did you know that in 1897 the Medical Society of the State of California (now CMA) proposed that all members of county medical societies be required to join CMA to “weld the profession more closely together, and increase the influence of the county society”? This was the first step in creating unitary membership in CMA and county societies; if you wanted to join one, you had to support both.
It was suggested that counties should collect an extra two dollars in dues from each member to be paid to CMA. Counties who refused to collect the extra $2 would be suspended. Although the plan met with some rebellion, it was eventually adopted and is still the principle followed today.
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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7. CMA Member Benefit of the Week: Managed Care Contracting Tools
To help physicians negotiate and manage complex third-party payor agreements, CMA has published two contracting toolkits, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations,” and “Managed Care Contracts Deciphered: The Physicians’ Guide to Their Rights and Obligations.”
Both of these managed care contracting toolkits have been bundled onto one CD, which is now available for purchase in the CMA bookstore. Members pay $40, nonmembers $100. (“Taking Charge” can also be downloaded free at the members-only website. Click on “Reimbursement Advocacy” under “Physician Advocacy.”)
Additional contracting resources can be found in CMA ON-CALL, the association’s online library of medical, legal, regulatory, and reimbursement information. These documents are free to members at CMA's members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in CMA's members-only website.
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. 2049 
