1. Outraged CMA Doctors Barrage DMHC with Phone Calls,
E-mails and Force Blue Cross to Delay New Fee Schedule
Responding to complaints from hundreds of CMA physicians, the Department of Managed Health Care (DMHC) has forced Blue Cross to delay implementation of its new fee schedule and take appropriate measures to notify doctors of the rate changes. The new implementation date is August 6.
According to DMHC, Blue Cross has agreed to make new the fee schedule available for download by Friday. The PDF download will include the proposed fees for all CPT codes.
As you’ve read in previous issues of CMA Alert, Blue Cross failed to provide physicians with timely access to the new fee schedule, leaving many physicians unable to assess the financial impact that the fee schedule changes will have on their practices. The new fees were scheduled to take effect June 1.
CMA first brought the problem to DMHC’s attention in early May, after learning that the fee schedule was not made available by April 15, as required by law. California’s unfair payment practices law (created by a CMA-sponsored bill) 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.
DMHC did nothing to stop the June 1 implementation, and took no action until hundreds of CMA physicians phoned and e-mailed the department to express their outrage. “Clearly, hearing the anger and frustration from the physician community made a difference,” says CMA President Anmol S. Mahal, M.D. “Our actions caused the DMHC to change course. We let regulators know we are a force to be reckoned with.”
When CMA recently surveyed members about this issue, a number of physicians not only reported to CMA that were they unable to access the new fee schedule, but also that they were not even notified by Blue Cross about the impending contract changes. DMHC has indicated to CMA that it will continue to investigate this failure.
CMA also believes Blue Cross is in violation of the RICO settlement, in which it agreed to provide greater notice of policy and procedure changes. CMA has filed a dispute with the RICO lawsuit compliance dispute facilitator.
Click here for more information.
Contact: CMA’s reimbursement help line, 888/401-5911 or jblack@cmanet.org.
2. Medicare Releases Final Quality Initiative Details
The Centers for Medicare & Medicaid Services (CMS) this week released the final specifications for its Physicians Quality Reporting Initiative (PQRI), which starts July 1. The specifications contain descriptions and clinical recommendation statements for each of the 74 performance measures and include instructions on how to code each measure’s numerator and denominator.
PQRI 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. The current reporting period is for claims with dates of service from July 1 through December 31. Claims must be received on or before February 29, 2008, to be included in the bonus payment calculation.
CMS has designated “G8300” as a test code for physicians who want to test their PQRI readiness. Physicians should also be aware that you must have an NPI to participate in the program. You will need to need to provide your NPI in the “Rendering Provider” field on the claim form.
Click here for more information.
Contact: Sandra Bressler, 415/882-5171 or sbressler@cmanet.org.
3. CIGNA Agrees to Retroactively Pay Previously Denied Claims
for CAD Mammography
CMA and representatives of various state medical societies have successfully resolved another RICO settlement dispute involving the payment of add-on codes (claims submitted for additional procedures by the same physician above and beyond the primary procedure). CIGNA has agreed to retroactively pay previously denied claims with add-on codes for computer-aided digital (CAD) mammography originally submitted between January 1 and October 10, 2004.
As you know, CIGNA in early 2004 settled CMA’s civil racketeering (RICO) lawsuit, which alleged that for-profit HMOs used fraud and other illegal activities to interfere in the physician-patient relationship. The case, which became the largest class-action health care lawsuit in U.S. history, allowed physicians to air profound grievances against an industry that had arrogantly and unfairly exploited them and harmed their patients for more than a decade.
In the settlement, CIGNA specifically agreed, among many other things, to pay all add-on codes from the date they became effective under the CPT system. The codes in question (CPT Codes 76082 or 76082 as add-on codes with 76090, 76091, or 76092) became effective January 1, 2004, but CIGNA did not begin paying those claims until October 10, 2004.
Resubmitting claims is simple. Download the claims resubmission spreadsheet from the RICO Resource Center and e-mail the completed spreadsheet to cadmammorebsubmit@CIGNA.com. You may also mail completed spreadsheets to CIGNA R&R Department P&C, P.O. Box 9018, Sherman, TX 75091-9018.
Claims can be resubmitted from June 1 to December 1.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
4. CMA Urges Elimination of Private FFS Medicare Advantage Plans
CMA has urged Congress to eliminate private fee-for-service plans from the Medicare Advantage Program, calling such plans “unwarranted insurance industry profit centers” that are siphoning-off valuable resources from the Medicare program at the expense of patients, physicians, and the taxpayers.
Private fee-for-service Medicare plans receive 20 to 50 percent more than fee-for-service physicians for providing the same services to Medicare beneficiaries. Big profit margins combined with weak oversight by the Medicare program have resulted in aggressive and deceptive sales practices and inefficient operations without any incentives to establish appropriate provider networks.
“These plans are not required to have adequate physician networks or meet any quality standards,” wrote Dr. Mahal in a letter to California Congressman Pete Stark, chairman of the powerful Ways and Means Health Subcommittee. “They are not providing value to patients and are allowed to hold physicians to untenable terms.”
Click here for more information.
Contact: Elizabeth McNeil, 415/882-3176 or emcneil@cmanet.org.
5. CMA-Sponsored Bill Would Require DMHC
Enforcement Actions to Make Physicians Whole
A CMA-sponsored bill making its way through the legislature would require Department of Managed Health Care (DMHC) enforcement actions to make physicians whole. The bill would require mandatory penalties for HMOs found by DMHC to have underpaid physicians, and would require those HMOs to automatically pay to physicians the full amount of underpayment plus interest. HMOs would also be prohibited from requiring physicians to resubmit underpaid claims to receive payment.
The bill (AB 1155) easily passed the Assembly this week by a vote of 52 to 25 and is now headed to the Senate.
For more information on this and other bills of interest to physicians, see CMA’s Legislative Hot List.
Contact: Susan Bassett, 916/444-5532 or sbassett@cmanet.org.
6. Blue Shield Clarifies Multiple Services Payment Policy
CMA has recently received some clarification from Blue Shield on its new multiple services payment policy, which takes effect July 1.
In a letter to physicians last month, the insurer announced a new multiple services payment policy, which will in some circumstances reduce reimbursement for multiple procedures provided on the same day. CMA asked Blue Shield to provide physicians with details on the codes affected by this new policy and the amount of the fee reductions. According to Blue Shield, the CPT codes impacted by this new policy are 97001 to 97840. There will be three payment tiers (with the first tier being paid at 100 percent). The actual amount of the fee reductions for second and third tiers will soon be available on Blue Shield’s secure provider website.
Included with the letter was a “provider allowance review” form to be used to request reimbursement amounts by CPT code. CMA expressed concern that the 20-day turnaround for fee schedule requests would make it difficult for most physicians to obtain this information prior to the July 1 effective date. According to Blue Shield, the 20-day turnaround mentioned in its letter was a typographical error. The actual turnaround time is 10 or fewer business days.
CMA has created a financial impact worksheet to help physicians assess the impact fee schedule changes will have on their practices based on their most commonly billed CPT codes.
Click here for more information.
Contact: CMA’s reimbursement help line, 888/401-5911 or jblack@cmanet.org.
7. Help Us Improve Access for Underserved Californians
CMA needs your help to make sure that the legislature includes money in the 2007-2008 state budget for the the Steve M. Thompson Loan Repayment Program. Please contact the key legislators listed below and urge them to fund this valuable program, which improves access to care for underserved populations in California. We are asking for a modest $5 million to keep this program alive.
This loan repayment program provides medical school loan repayment grants of up to $105,000 in exchange for a three-year service commitment in a medically underserved area of the state. The program, created under a CMA-sponsored law in 2002, was renamed last year in honor of Thompson, CMA’s longtime vice president of government relations, who passed away in August after a very short but precipitous battle with cancer.
The legislators we are targeting are:
- Senate Budget Committee Chair Denise Ducheny (D-San Diego)
- Senate Republican Leader Dick Ackerman (R-Orange County)
- Senate Democratic Leader Don Perata (D-Oakland)
- Assembly Budget Committee Chair John Laird (D-Santa Cruz)
- Assembly Republican Leader Michael Villines (R-Merced)
- Assembly Democratic Leader Fabian Nunez (D-urban Los Angeles)
Please contact one or more of these legislators as soon as possible, as the budget process is moving very quickly.
Click here for more details, including contact information and sample letter.
Contact: Susan Bassett, 916/444-5532 or sbassett@cmanet.org.
8. CMS Hosts Call to Discuss NPI Dissemination Policy
The Centers for Medicare & Medicaid Services is hosting a conference call to discuss its new NPI data dissemination policy. The policy, announced last week, will allow physicians and other covered entities to soon be able to look up NPIs by simply entering the provider or facility name into an online database. This online lookup will be available on June 28, 30-days after CMS’s official NPI data dissemination policy was published in the Federal Register.
The call is Thursday, June 14, from 11 a.m. to 12:30 p.m. Pacific Time. Physicians are encouraged to register as soon as possible, as phone ports are limited and these calls often fill up. Registration closes 24 hours prior to the call.
Click here for more information.
9. Member Benefit of the Week: Workers’ Comp Insurance
Don’t renew your workers’ compensation policy without first checking with CMA’s affinity partner, Marsh. Rates have dropped significantly in the past year, and qualifying members are eligible for additional savings when they purchase or renew their policies through Marsh. Call Marsh at 800/842-3761 for information.
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. 2098
