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1. CMA Helps Physicians Minimize Part D Hassles
Now that the deadline for eligible seniors to enroll in Medicare’s Part D prescription drug plans has passed, physicians will likely notice increased administrative hassles when prescribing drugs for Medicare patients.
During the enrollment period, plans “opened” their formularies in an effort to reduce phone calls and formulary exception requests from patient and physicians. With the deadline passed, plans will strictly enforce their prescription drug formularies and patients may find that prescriptions plans had previously paid for are not actually included in the plans formularies. Physicians will likely need to appeal prescription denials or request coverage exceptions on behalf of their patients.
Part D plans are permitted to make changes to their formularies as approved by the Centers for Medicare & Medicaid Services. Physicians should be aware, however, that Part D plans cannot limit or exclude previously covered drugs that were prescribed for enrollees before the formulary was changed, unless there are clear scientific or cost reasons (such as the availability of a generic version of the drug or new clinical information).
To minimize administrative Part D hassles, physicians are encouraged to:
- Verify patients’ insurance information before they are treated.
- Look up patients’ formularies before writing prescriptions. Part D
formularies can be accessed at no charge from Epocrates using your PDA or desktop computer.
- Use the standardized exception and prior authorization form to request an exception in coverage for nonformulary drugs.
Click here for more details, including contacts for all the Part D plans.
Contact: Kelly Frost 916/551-2883 or kfrost@cmanet.org.
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2. CMA Seeks Examples of Drug Preauthorization Problems
Many health plans impose burdensome preauthorization requirements to discourage physicians from prescribing drugs that are not in the plans’ formularies. At last year’s annual meeting, CMA’s House of Delegates passed a resolution that instructed the association to “prioritize its managed care advocacy efforts to provide relief to physicians from burdensome health plan preauthorization requirements for medically necessary prescription drugs.”
To defend you and your patients, CMA needs examples of problem areas and urges physicians and/or their staff to provide CMA with specific examples of drug preauthorization difficulties that you have experienced, including a plan that:
- requires preauthorization for prescription renewals for patients with chronic or urgent conditions
- only accepts preauthorization or exception requests directly from the physician by telephone, rather than by fax or e-mail
- fails to respond to preauthorization or exception requests within 72 hours
- requires preauthorization for all drugs in a class
- requires burdensome preauthorization documentation
- takes drugs off its formulary and refuses to pay for previously covered drugs that were prescribed for its enrollees before the formulary was changed.
- requires a patient to go through step therapy, even when not in the patient’s best medical interests, before authorizing a nonformulary drug that the physician believes to be medically necessary.
Help us fight health plan interference in the doctor-patient relationship. For each problem, please download the complaint form and fax it with any relevant supporting documentation to CMA at 415/882-5143. Your responses will be carefully reviewed by CMA’s Committee on Medical Services.
Click here for more information.
Contact: CMA's legal information line, 415/882-5144 or legalinfo@cmanet.org.
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3. Aetna Settles Modifier 25 RICO Settlement Compliance Dispute
Aetna last week settled another RICO compliance dispute and agreed to start paying physicians for evaluation and management (E&M) services and other non-E&M services provided to the same patient on the same day when billed with modifier 25. Despite agreeing in the settlement to pay these codes, many such claims were being denied.
CMA has posted on its website a complete list of the 200-plus non-E&M service procedure codes affected by this agreement. Aetna has agreed to begin paying these codes immediately. The plan will also automatically reprocess all improperly rejected claims with dates of service on or after July 1, 2004. Physicians who filed disputes on this issue will be paid for rejected claims dating back to May 21, 2003 (the date of the original settlement agreement). This is worth at least $3 million a year in additional payments to physicians.
Aetna has also agreed to participate on a task force with state medical society representatives to revise its other payment policies that improperly deny physicians payment. These policy changes—worth a minimum of $1.7 million a year in additional payments to physicians—will apply to claims with dates of service after May 1, 2006. Aetna will automatically reprocess relevant claims as necessary.
This compliance dispute is different and separate from last month’s announcement that Aetna had agreed to pay physicians for problem-oriented E&M services provided during a preventive services visit, when billed with modifier 25. (Click here for more information on the earlier, modifier 25 decision.)
Click here for more details on CMA’s RICO lawsuit, including the commitments made by the six settling health plans and information on how to file a dispute if you believe a plan is not in compliance with its settlement terms.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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4. CMA Encourages Physicians to Get Involved in Pandemic Planning
CMA has heard from many physicians interested in getting involved in public health pandemic planning efforts. The best way to help is at the local county level. Most county health departments have already begun developing local pandemic response plans and physician participation is welcome. In addition, the governor has proposed that all requests for state pandemic preparedness funds will require approval of local health officers. Interested physicians should contact their county medical societies for more information.
Pandemic plans are also underway at the state and national levels. CMA is an active participant in a number of work groups, including the California Department of Health Services Joint Advisory Committee (JAC) on Public Health Preparedness, that meet regularly to discuss related public health issues.
Click here for more information.
Contact: Robin Flagg, 916/415-5110 or rflagg@cmanet.org.
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5. Governor’s Revised Budget Includes
$400 Million for Public Health Preparedness
The Schwarzenegger administration released its revised 2006-2007 budget proposal. The $131.1 billion spending proposal released Friday includes substantial funding for statewide disaster and pandemic preparedness. The budget proposal also allocates funds to increase enrollment in county-based children’s health care initiatives.
Although the state’s fiscal outlook is positive, the budget does not include a long-overdue rate increase for fee-for-service Medi-Cal providers.
Click here for highlights of the health care issues addressed in the budget proposal and a statement about the budget from CMA CEO Jack Lewin, M.D.
Contact: Lisa Folberg, 916/444-5532 or lfolberg@cmanet.org.
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6. Highlights from the Sixth Annual Adult Immunization Summit
CMA again this year cosponsored the California Adult Immunization Summit. At the sixth annual meeting, held earlier this month in Oakland, CMA and other members of the California Adult Immunization Coalition (CAIC) discussed several public health issues, including strategic planning for public health emergencies, such as a bird flu pandemic.
Participants also discussed adult immunizations for a number of diseases including influenza, pneumonia whooping cough, chicken pox/shingles, human papilloma virus, and meningitis. Other topics covered at this year’s summit were vaccine distribution, immunization registries, immunizations for special populations (such as college students and nursing home residents), and new and developing vaccines.
Click here for more information.
Contact: Robin Flagg, 415/882-5110 or rflagg@cmanet.org.
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7.
 150th Anniversary Trivia: Did You Know?
Did you know that in 1902 the official journal of the association (what would become the Western Journal of Medicine) became one of the first medical publications in the nation to reject advertisements for products of questionable medical value?
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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8. Member Benefit of the Week: ON-CALL Medical-Legal Information Library
CMA ON-CALL is an online library that contains over 3,000 pages of medical-legal, regulatory, and reimbursement information. The searchable library contains all the information available in the California Physician’s Legal Handbook, an annual publication of CMA’s Center for Legal Affairs.
ON-CALL documents are available free to members at CMA’s members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in CMA’s online bookstore.
If you haven’t taken advantage of this extraordinary resource, spend a few minutes browsing the ON-CALL index, and see what you’ve been missing.
Click here for more information about the benefits and discounts available to CMA members.
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No. 2052 
