|
1. Blue Shield Fee Schedule Changes Take Effect July 1
Blue Shield of California recently notified physicians of changes to its standard physician fee schedule that will take effect July 1. In a letter to physicians on May 1, Blue Shield notified physicians that it would be making changes to the fee schedule, but failed to provide details about the changes. The letter says only that Blue Shield plans to modify payment levels for many CPT codes, some being increased and others decreased.
CMA believes that this type of “notification” is not only unfair and burdensome, but also illegal. State law requires health insurers to provide physicians with at least 45 days advance notice of any material change to their contracts, and the opportunity to terminate the contract before the change takes effect. “First, there is no notice of the change,” wrote CMA legal counsel Astrid Meghrigian in a letter to Blue Shield last week. “The letter does not provide underlying information concerning the change itself; rather, it merely notifies providers that there will be changes and sets forth a complicated process for providers to follow in the event they wish to know what these changes are.” CMA also believes that Blue Shield is required by law to provide fee schedule information electronically. Currently, physicians must either call or fax a request to the insurer and wait 10 days for a response.
Although CMA has asked Blue Shield to postpone implementation of these fee schedule changes and provide physicians with electronic access to the new rates, you should not wait to begin assessing the impact the changes will have on your practice. To help you, CMA has published a toolkit available free to members at CMA’s members-only website, http://www.cmanet.org/member. Included in the toolkit is CMA’s financial impact worksheet, which will help you calculate the impact of the fee schedule changes based on your most commonly billed CPT codes.
Physicians are also urged to read CMA’s contracting toolkit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting.” This toolkit was designed to help physicians analyze proposed fee schedules and negotiate and manage complex third-party payor agreements. It is available free to members at the members-only website. Nonmembers can purchase the toolkit for $100 in the CMA bookstore, http://www.cmanet.org/bookstore.
Click here for more information.
Contact: Jodi Black, 916/551-2863 or jblack@cmanet.org.
2. NHIC Extends 855R Deadline for Northern California Physicians
With the official NPI implementation date upon us, California’s Medicare carrier – NHIC – is taking steps to ensure all providers are properly enrolled so that their payments will not be interrupted. As we told you in our last Alert, NHIC reports that the payments of more than 5,000 physicians who work for or contract with groups in Northern California are at risk. This impacts groups of all sizes.
Affected physicians must submit updated 855R forms for each of the groups they bill for no later than August 1. (NHIC has pushed back the deadline, originally June 1, to August 1.) This form reassigns their Medicare payment to their group(s). If the forms are not submitted by the deadline, groups will not get paid for the physicians’ Medicare services after August 1.
CMA strongly urges all physicians who work for groups or contract with groups in Northern California to contact the NHIC hotline at 877/527-6613 to ensure that you have filled out the required 855R form for each of the groups to which you want to reassign your Medicare payments. Physicians who enrolled as Medicare providers prior to 2006 may also need to fill out form 855I.
Groups can help physicians fill out these forms, but the physicians must sign them. To complete the 855R, physicians will need their NPI, the tax ID number for each of the groups to whom they want to assign payments, and the signatures of the groups’ authorizing agents. The authorizing agent’s signature is required.
Click here for more information.
Contact: Frank Navarro, 888/401-5911 or fnavarro@cmanet.org.
3. CMA Physicians Tell DMHC that Balance Billing Regulations
Are Gift to HMOs; Comment Deadline Extended to June 3
At three public hearings over the past two weeks, doctors organized by CMA and county societies asked the Department of Managed Health Care (DMHC) to withdraw its unauthorized regulation prohibiting anesthesiologists, emergency room doctors, pathologists, and radiologists from billing HMO patients for health care services rendered but unpaid by HMOs. CMA believes DMHC has no authority to propose the regulation and that it attacks the future viability of physician practices.
The new regulation defines “unfair billing patterns” to include the practice of balance billing patients when their HMOs fail to pay fairly for emergency services provided to their enrollees. In other words, balance billing by hospitals and hospital-based physicians – including on-call specialists – would be considered an unfair and therefore illegal billing practice. The proposal neither provides for interim payment in the event of a billing dispute, nor does it mention a dispute resolution process, as previous proposals have done.
At the hearings, physicians told DMHC officials that the proposal is a giveaway to the HMO industry at the expense of physicians, patients, and the future health of emergency services in California. Unlike previous proposals, this version does nothing to regulate or obligate HMOs in any manner. It does not address the key underlying problems of unfair contracts, which result in inadequate physician networks, and chronic and pervasive underfunding of emergency care by insurance companies.
CMA has submitted a thorough and strong written response in opposition this proposal. CMA extends its gratitude to all physicians who testified and shared their views against the regulations and continues to urge physicians to submit written comments to DMHC to protest its proposed anti-physician regulations. For more information, including talking points and instructions on how to file written comments, contact Armand Feliciano in CMA’s Center for Medical and Regulatory Policy. The deadline to submit comments has been extended to June 3.
Click here for more information.
Contact: Armand Feliciano, 916/444-5532 or afeliciano@cmanet.org.
4. New Medical Staff Standard Gives Physicians
Greater Control of Patient Care
After years of revisions and controversy, the Joint Commission’s Medical Staff Standard 1.20 (MS 1.20) has been finalized and will take effect July 1, 2009. Not surprisingly, MS 1.20 alarms the hospital community, as it gives the medical staff a greater role in ensuring safety and quality of patient care, and considerable efforts are being made to have these new standards changed yet again.
CMA is urging the Joint Commission to retain the standards it so carefully crafted to protect patient welfare through transparency. “As currently written… MS 1.20 will protect patients significantly in today’s strained environment and the benefits to be achieved by this standard by far outweigh any incidental costs that may be required for compliance,” wrote CMA President Richard S. Frankenstein, M.D., in a letter to the Joint Commission earlier this month. “Retreating from the patient-protective stance the Joint Commission has taken will only be viewed as a tremendous step backwards for medical staff self-governance, and any ‘mitigating’ efforts would only feed the dangerous environment that already exists.”
CMA encourages medical staffs to support the underlying concepts behind MS 1.20 by beginning to implement MS 1.20 and to amend their bylaws to be consistent with the new standards. CMA’s 2008 Model Medical Staff Bylaws—which incorporate the new standard—are now available in the CMA bookstore, http://www.cmanet.org/bookstore. Members of CMA’s Organized Medical Staff Section receive a free copy. All other members pay $75, nonmembers $405.
Contact: Valerie Satt, 916/551-2053 or vsatt@cmanet.org.
5. Anthem Blue Cross Wants Money Back
for Some Bone Density Studies
CMA has learned that Anthem Blue Cross has identified overpayments made to physicians for a select group of bone density study CPT codes. Specifically, the overpayments were made on over 6000 claims for CPT codes 77080, 77081, and 77082 (dual energy x-ray absorpitometry services) with dates of service of January to December 2007.
Affected were claims for multiple units or multiple line items of the same code. According to CPT guidelines, codes 77080-77082 include “1 or more sites,” therefore each code should only have been used once per claim.
Physicians are encouraged to review any refund requests received to ensure that written requests for overpayments are within 365 days of the date of original payment, as required by law. Physicians who wish to contest the overpayment must notify the payor in writing within 30 working days.
Physicians who have questions about the refund requests can contact Blue Cross Risk Management at 818/234-3289.
For more information on payor requests for refunds, please see CMA ON-CALL Document #0135, “Plan Requests for Refunds from Physicians.” ON-CALL documents are free to members at the members-only website, http://www.cmanet.org/member. Nonmembers can purchase ON-CALL documents for $2 per page in the CMA bookstore, http://www.cmanet.org/bookstore.
Contact: Jodi Black, 916/551-2863 or jblack@cmanet.org.
6. CIGNA Agrees to Stop Bundling Developmental Screening Code
CIGNA recently agreed to pay physicians for developmental screening services (CPT 96110) when submitted with evaluation and management (E&M) services and billed with modifier 25. Previously, the insurer had bundled these codes.
This welcome payment change came as a result of compliance disputes filed by several pediatricians under the RICO settlement reached with CIGNA in 2004. Although the CIGNA settlement has expired, the insurer has agreed to make this payment change effective May 1.
The settlements with Aetna, HealthNet, Humana, WellPoint, and the Blue Cross/Blue Shield Association remain in effect. For more information about your rights under the settlements or if you believe that any of these companies is violating the settlement terms, please call CMA’s reimbursement help line, 888/401-5911.
7. Governor’s Budget Slashes Health and Human Services by $3.4B
The Schwarzenegger administration recently released its revised 2008-2009 budget proposal, which includes a total of $3.4 billion in cuts to health and human services in an effort to reduce the state’s $17.2 billion budget deficit. The state’s financial outlook is even bleaker then anticipated when the Governor released his previous budget proposal in January. Schwarzenegger cut an additional $1.1 billion from health and human services than he had his initial budget proposal.
The proposed budget would, among other things, cut back Medi-Cal eligibility for certain adults from 100 percent of the federal poverty level ($17,600 annually for a family of three) to 61 percent ($10,736). The Governor estimates that this cut will save $31 million. The proposal would also eliminate coverage for most nonemergency services for recently-documented and undocumented immigrants, with an estimated savings of $86 million.
Additionally, the budget maintains the 10 percent provider rate cut that was proposed by the Governor in January and subsequently approved by the Legislature. Earlier this month, CMA and a coalition of health care providers filed a lawsuit against the state of California to stop the Medi-Cal provider rate cut, which is scheduled to take effect on July 1.
“These budget cuts will devastate access to health care for millions of poor Californians and will wreak havoc on the ability of middle class Californians to meet their health care needs,” says CMA President Richard S. Frankenstein, M.D. “If this budget somehow passes and even a fraction of these cuts go into effect, Governor Schwarzenegger’s legacy to the people of California will not be the health care reform he has promised, but instead a health care system damaged beyond belief.”
Click here for more information.
Contact: Lisa Folberg, 916/444-5532 or lfolberg@cmanet.org.
8. NPI Deadline Has Passed
As of May 23, all physicians must use only their 10-digit National Provider Identifiers on all electronic claims with public and private payers. Physicians must also use their NPI when submitting paper claims to Medicare and some other payors.
On March 1, Medicare carriers started rejecting claims that did not have NPIs, but kept approving ones that contained both NPIs and legacy identifiers. Now, in the final step of the transition, Medicare will soon to instruct carriers to reject claims that are not NPI-only. Private payers that hadn’t already made the switch were also required to do so by May 23.
If you send Medicare a transaction with a Medicare legacy identifier in any of the provider fields, your claim will be rejected. These transactions include all electronic and paper claims (837I, 837P, NCPDP, DDE and paper CMS-1500 and UB-04), the 276/277 claims status transaction, the 270/271 eligibility transaction, 835 remittance advice and SPR paper remittance.
Click here for more information.
Contact: CMA’s reimbursement help line, 888/401-5911 or fnavarro@cmanet.org.
9. Please Complete the Physicians Foundation Survey
The Physicians Foundation for Health Systems Excellence has mailed a survey to over 300,000 physicians nationwide to get their views on today’s medical practice environment, with the goal of giving physicians a greater voice in health care policy debates.
Check your mail. Don’t miss the opportunity to participate in one of the most ambitious physician surveys ever attempted. The survey is due back by Wednesday, June 25.
For more information, visit http://www.physiciansfoundations.org.
10. CMA Foundation Has Moved
The CMA Foundation has moved its staff to an office in Natomas, a community adjacent to Sacramento, to accommodate its growing staff.
Please make note of the following contact changes:
- Address: 3835 North Freeway Blvd., Suite 100, Sacramento, CA 95834
- Phone: 916/779-6620
- Fax: 916/779-6658
- URL: www.thecmafoundation.org
New staff extensions and e-mails can be found at www.thecmafoundation.org, under “What’s New.”
Contact: Liz Burdick, 916/779-6639 or lburdick@thecmafoundation.org.
11. 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.
EPL insurance provides protection against claims of wrongful termination, harassment and discrimination made by employees or patients.
Limits of $250,000, $500,000, or $1,000,000 are available, with low minimum premiums beginning at $750.
Call a Marsh Client Service Representative at 800-842-3761 for more information.
Click here for more information on your membership benefits.
Contact: CMA’s member service center, 800/786-4CMA or info@cmanet.org.
| 
No. 2133
