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1. State Investigating PacifiCare/United Healthcare Business Practices
CMA this week learned that the Department of Insurance (DOI) and the Department of Managed Health Care (DMHC) have launched an investigation of PacifiCare/United Healthcare. This announcement comes just a few months after CMA informed state regulators that the association had been receiving a large number of complaints from physicians about the insurer, particularly with regard to physician contracting and urged them to investigate.
Among the complaints were charges of chronic delays processing new contracts and contract terminations. These delays not only have caused patients to be misinformed about physicians’ participation status, but also have resulted in significant administrative hassles and payment delays for physician offices. Physicians are also reporting that the insurer has failed to load contracted rates correctly and has been unresponsive to their phone calls, letters, and e-mails.
“We are looking into a wide range of conduct by these companies and will use the full array of investigative and enforcement mechanisms available to us,” wrote David Link, DOI deputy commissioner, and Ed Heidig, DMHC deputy director, in a letter to CMA.
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Contact: Aileen E. Wetzel, 916/444-5532 or awetzel@cmanet.org.
2. Quality Matters: Are Your Billing Systems Ready
for Medicare Quality Reporting Program?
The Centers for Medicare & Medicaid Services (CMS) has designated “G8300” as a test code for physicians who want to test their readiness for the Physicians Quality Reporting Initiative. The quality reporting initiative, which begins in July, establishes financial incentives – bonus payments of 1.5 percent of total allowed charges for covered Medicare physician services – for physicians who participate in this voluntary program.
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Contact: Sandra Bressler, 415/822-3171 or sbressler@cmanet.org.
3. You Wanted to Know: I Missed the NPI Deadline — Now What?
As you know, yesterday was the official deadline to obtain your NPI. Despite all the talk about a one-year “grace period,” the reality is that if you don’t have your NPI your claims could be delayed or denied.
The Centers for Medicare & Medicaid Services (CMS) last month announced a one-year grace period during which physicians will not be penalized for noncompliance as long as they have a contingency plan in place and are able to demonstrate “good faith efforts” to comply with the regulations.
To prove good faith, you must obtain your NPI as soon as possible. Since there are very few barriers to obtaining an NPI (it is a simple application), few physicians can argue that they need a contingency plan! Apply online at https://nppes.cms.hhs.gov or call the NPI Enumerator at 800/465-3203 and request a paper application form.
Obtaining an NPI now will help you avoid cash flow disruptions. Even though the grace period also allows payors to continue accepting legacy ID numbers until May 23, 2008, they may at any time during the next year decide to stop accepting legacy numbers and to only accept NPIs.
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Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
4. CMA President Testifies Before Ways and Means
Committee on Medicare Payment Reform
CMA President Anmol S. Mahal, M.D., last week testified before the powerful U.S. House Ways and Means Committee. Dr. Mahal was invited by committee chair Congressman Pete Stark (D-Calif.) to speak about Medicare payment reform.
As you know, CMA recently presented to Congress a multipronged plan to overhaul the broken Medicare payment system. CMA’s plan, which has been very well received on Capitol Hill, would, among other things, eliminate the flawed sustainable growth rate (SGR) formula, provide payment updates based on practice cost increases, and update the geographic payment localities. CMA has also proposed a number of five-year demonstration projects to study cost-saving mechanisms to coordinate care, manage volume, and reward appropriate use of medical services. Permanent implementation of worthy demonstration programs would replace the SGR spending target as the Medicare physician cost containment mechanism.
“As California physicians, we agree we must do our part to provide the highest-quality care in the most efficient possible manner,” Dr. Mahal told the committee. “We at CMA are committed to working with Congress to improve the Medicare program by sharing our knowledge of evidence-based medicine and our experience with programs that attempt to manage costs and care.”
Congressional leaders have applauded CMA for developing a proactive solution to resolve the problem, rather than just complaining about the reimbursement rate cuts.
Dr. Mahal was asked specifically to comment on peer comparison programs. Dr. Mahal participates in an IPA peer comparison program that rewards physicians through bonus payments for high marks on quality, utilization, and patient satisfaction. More important, the program fosters self-improvement by providing physicians with confidential peer comparison information, helping them better understand their practice patterns and improve patient care.
“Many California medical groups and IPAs who run sophisticated managed care systems employ utilization profiling methods, but the vast majority of these groups use them only for educational purposes,” said Dr. Mahal. “The educational aspect of comparative information is vital to the success of these programs.”
Dr. Mahal told the committee that while CMA does not have specific policy on this program, the association does support peer comparison programs as an educational tool for physician self-improvement.
However, Dr. Mahal also told the committee that before implementing any program that ties reimbursement to utilization performance, Medicare must test various program designs through demonstration projects, such as those recommended by CMA as part of its Medicare reform plan. Because of the potential impact on patient care, “many safeguards would be necessary before such a complex program could be considered in the Medicare fee-for-service system,” Dr. Mahal said.
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Contact: Elizabeth McNeil, 415/8827-3376 or emcneil@cmanet.org.
5. Have You Had Trouble Getting Information on
Blue Cross Fee Schedule Changes?
CMA has formally requested that the Department of Managed Health Care step in and delay implementation of Blue Cross fee schedule changes that are scheduled to take effect June 1. Blue Cross has failed to provide physicians with timely access to the proposed fee schedule, leaving many physicians unable to assess the financial impact that the fee schedule changes will have on their practices.
CMA believes that Blue Cross is in violation of state law, which requires insurers to fully disclose to contracting physicians their fee schedules and payment rules and to notify physicians in writing 45 days before instituting any changes to fee schedules and payment rules. CMA also believes Blue Cross is in violation of the RICO settlement agreement, in which it agreed to provide greater notice of policy and procedure changes.
CMA is collecting data to provide DMHC with additional examples of difficulties and delays practices are experiencing when attempting to obtain the new Blue Cross fee schedule.
Please take a few minutes to complete a brief survey.
Contact: CMA's reimbursement help line, 888/401-5911 or gfonseca@cmanet.org.
6. Member Benefit of the Week: Magazine Discount Program
The CMA Magazine Program gives members up to 50 percent off subscriptions to hundreds of popular magazines. The same low rates apply to new subscriptions and renewals. Renewals with the discount are available no matter how your subscriptions were originally ordered.
If you find a lower advertised price for any magazine offered through this program, simply send in the promotional offer with your order and pay the lower amount. Subscriptions for both office and personal use are available through this membership program.
For more information, call 800/603-5602, e-mail cma@buymags.com, or visit http://www.buymags.com/cma.
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. 2096
