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1. Want to Know Which Health Plans Rank Highest in Physician Satisfaction?
CMA affinity partner athenahealth recently released a health-plan ranking system that scores health plans based on how they process physician claims. The system ranks plans in seven categories, including speed of payment, denial rates, and first-pass pay rates.
Athenahealth provides web-based practice management services, which includes eligibility verification, claims submission, and insurance collection. The PayerView index ranks claim performance based on data from the fourth quarter of 2005 collected by athenahealth on more than 7,000 national and regional payers.
The system allows physicians to view the health plan rankings nationally or regionally. As a favor to CMA, athenahealth has provided the association with California-specific rankings, as well.
Click here for more information.
Contact: CMA’s Center for Economic Services, 916/551-2061.
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2. Honor CMA On Its 150th Birthday:
Publish a Tribute in CMA’s Commemorative Book
To honor 150 years of “helping physicians help patients,” CMA is producing a commemorative book.
In this CMA anniversary book, we offer you the opportunity to pay tribute to your CMA in the way you see fit. You can honor fellow members, county societies, health leaders, health care achievements, and even your family and friends. This glossy, handsome commemorative book will be distributed to CMA’s members and beyond. Please join us in celebrating this major milestone in our history.
Don’t know anything about graphic design? Don’t worry—we can do it for you. All we need you to provide are the pictures and text that you want to have in your tribute.
Click here for more information.
Contact: 888/231-7451 or advertising@cmanet.org.
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3. CMA Opposes Attempt to Change DMHC’s
Criteria for Determining 'Reasonableness' of Fees
The California Association of Physician Groups (CAPG) recently submitted a petition to the California Department of Health Services urging the department to reopen its Claims Settlement Practices Regulations and modify the criteria used in the regulations for determining the reasonableness of fees charged by noncontracted physicians for emergency services provided to health plan enrollees. Specifically, CAPG wants DMHC to modify the Gould Criteria, the nationally accepted standard for determining fair and reasonable payment for health care services.
CMA strongly objects to reopening this settled issue and believes CAPG’s recommended Gould modifications would undermine ongoing efforts to create a fee dispute resolution mechanism, ultimately hurting physicians in all modes of practice. Unlike CMA, which has membership from across the spectrum of practicing physicians in California, CAPG represents large, capitated medical groups that operate under the delegated model.
The Gould Criteria require consideration of the following evidence when deciding the “reasonableness” of fees charged by a noncontracted physician:
- The physician’s training, qualifications, and length of time in practice
- The nature of the services provided
- The fees usually charged by the physician
- The fees usually charged in the physician’s geographic area
- Other relevant economic details of the physician’s practice
- Any unusual circumstances
CAPG wants to add three additional criteria to DMHC’s claims settlement regulations:
- Average payor contract rates in physician’s geographic area
- Fee schedule rates of governmental payors
- Average amount for the service paid to and accepted by noncontracted providers in the geographic area
The last bulleted item may merit consideration in a discussion of reasonableness, if such data were available. However, CMA believes that accepting average contract rates and governmental payors' fee schedules are irresponsible recommendations that would in a very short time force all physicians to accept whatever health plans and government payors choose to pay.
CMA recently wrote a letter to DMHC Director Lucinda Ehnes, urging her to deny CAPG’s request to reopen the regulations. “The current regulation reflects the only judicially approved criteria for evaluating the usual, customary and reasonable fees of noncontracted physicians,” wrote CMA CEO Jack Lewin, M.D. “In adopting this regulation, the department properly refrained from crossing the line into impermissible rate regulation, while still providing guidance.”
CMA understands that risk-bearing organizations (RBOs) may be having difficulty complying with the Claims Settlement Practices Regulations. CMA has urged DMHC to ensure that capitation payments to RBOs are adequate to cover the costs of complying with these regulations.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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4. CMA Defends Women’s Reproductive Rights
CMA recently submitted an amicus brief in support of a lawsuit brought by the State of California challenging a federal abortion-related spending restriction that could deny California agencies more than $49 billion in federal funds. The restriction, known as the Weldon Amendment, essentially allows “health care entities,” to refuse to perform, pay or provide coverage for, or refer for abortions regardless of federal, state, or local laws to the contrary.
Although California law protects the right of religious facilities and individual health providers to refuse to participate in abortion services, California law requires that such services be provided in medical emergencies. Under the Weldon Amendment, California could be denied tens of billions of dollars of federal funds if it enforces state laws, which require that physicians treat all patients whose health or life is endangered, including from dangers that arise from pregnancy and can be prevented only by emergency abortion.
“The amendment could deprive women who need emergency abortions—and only women who need emergency abortions—from the protections afforded to all other patients by California’s regulation of the medical profession,” wrote CMA in its brief. “Congress would not think to prohibit California from disciplining a doctor who refused to perform CPR for patients suffering from cardiac arrest, refused to operate on patients suffering from severe cranial bleeding…or refused to give fluids to patients who were dehydrated.”
CMA’s brief explained that there are a variety of reasons that women develop medical complications during pregnancy that jeopardize their lives and require immediate abortions. CMA’s brief argues that the Weldon Amendment violates women’s constitutional right to seek lifesaving emergency abortion care.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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5. CMA Past President Takes the Reins as AMA’s 161st President
CMA Past President William G. Plested, M.D., was installed this week as AMA’s 161st president at the association’s annual meeting in Chicago.
Dr. Plested, a cardiothoracic surgeon in private practice in Santa Monica, is a passionate defender of patients’ rights and the right of physicians to make medical decisions with their patients without third-party interference.
Dr. Plested was CMA president from 1989 to 1990. His involvement in organized medicine began in the 1970s, when California physicians faced a medical liability crisis. Dr. Plested joined with physicians statewide in seeking a solution. The result was passage in 1975 of California’s Medical Injury Compensation Reform Act, which has become the national model for medical liability reform.
Click here for more highlights from AMA’s annual meeting, including resolutions introduced by the California delegation.
Contact: Ginnie Yee, 415/882-5170 or gyee@cmanet.org.
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6. Quality Matters:
100k Lives Campaign Surpasses Goal, Prevents 122k Avoidable Deaths
In December 2004, the Institute for Healthcare Improvement (IHI) launched its “100k Lives Campaign,” challenging the nation’s hospitals to save 100,000 lives in 18 months by implementing practices proven to reduce infections, medical complications, and adverse outcomes.
IHI recently announced that it not only met its 100k goal, but exceeded it. In the campaign’s first 18 months, more than 3,000 hospitals signed on, including 170 in California, saving an estimated 122,300 lives. Participating hospitals implemented some or all of the campaign’s lifesaving best practices, including:
- deploying rapid response teams at the first sign that a patient’s condition is deteriorating
- preventing infections after operations by taking proper steps during and immediately before and after surgery
- preventing adverse drug events by maintaining and monitoring a single
master list of all medications a patient is taking
Although the campaign has reached its 18-month milestone, there is still much work to be done. CMA encourages all California hospitals to join IHI’s campaign to help prevent avoidable deaths. There’s no cost to participate.
Click here for more information.
Contact: 866/787-0831.
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7. CMA Foundation Accepting Nominations for
Ethnic Physician Leadership Award; Deadline Is July 28
The CMA Foundation and its Network of Ethnic Physician Organizations (NEPO) is accepting nominations for their second annual Ethnic Physician Leadership Award. The award, given to a physician who has made outstanding leadership contributions to ethnic communities in California, will be presented at the NEPO Annual Summit, September 30 in Los Angeles.
This award, made possible by a grant from the Pfizer Medical Humanities Initiative, was created to inspire physicians and promote leadership, caring, and compassion in medicine. Last year’s award went to Rolland C. Lowe, M.D., for serving as a teacher, role model, and trailblazer for ethnic physicians, and helping to create both NEPO and CMA’s Ethnic Medical Organization Section.
The recipient will receive a $1,000 honorarium. The recipient’s ethnic physician organization (or similar organization of his or her choice) will also receive a $1,000 grant to carry out community health and patient advocacy projects.
Nominations will be accepted from individuals and organizations. The deadline to submit a nomination is Friday, July 28.
Click here for more information or to download a nomination form.
Contact: Carol A. Lee, 916/551-2562 or clee@cmanet.org.
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8. Aetna May Owe You Money; Don’t Miss Your Chance to Collect
Don’t miss your opportunity to submit unpaid “add-on” claims to Aetna for adjudication. The deadline to submit claims is July 14.
As reported previously in Alert, Aetna had been denying claims with add-on codes for CAD mammography (CPT codes 76082 and 76083) and myocardial perfusion testing (CPT codes 78478 and 78480), in violation of its RICO settlement agreement. Some physicians even stopped filing claims because Aetna was not paying them. A number of physicians filed RICO settlement compliance disputes and, as a result, in 2005 Aetna began paying for these add-on codes.
CMA and the physicians who filed compliance disputes continued to push Aetna to retroactively pay the previously denied claims for add-on codes. As a result of the compliance disputes and CMA’s ongoing RICO settlement enforcement, Aetna agreed in April to retroactively pay claims with add-on codes for CAD mammography and myocardial perfusion testing with dates of service on or after January 1, 2004.
The money involved is not insignificant. The 19 physicians and physician groups who filed compliance disputes were paid a combined total of $678,000, with one group receiving over $250,000.
The process for resubmitting previously denied claims is described on Aetna’s provider website. Click on “Add-On Code Claims Payment” in the “Features” section in the lower right corner of the top web page. Physicians should submit new claims following standard billing procedures.
More details are available from Aetna’s provider service center (888/632-3862 for PPO plans or 800/624-0756 for HMO plans). Have your tax ID number available when you call.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
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 9. 150th Anniversary Trivia: Did You Know?
Did you know that in 1883 Dr. Thomas Huntington established the West’s first antiseptic operating room at Central Pacific Railroad General Hospital in Sacramento?
Not only was Dr. Huntington an antiseptic surgery pioneer, but he is also credited with advancing other surgical techniques, including the use of catgut to suture wounds and surgical openings.
Dr. Huntington was a member of the Medical Society of the State of California (now CMA) for many years, serving as chairman of the committee on surgery in 1887 and again in 1897. He also served as president of the Sacramento Society for Medical Improvement (now the Sierra Sacramento Valley Medical Society) in 1890 and became president of CMA in 1911.
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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10. Member Benefit of the Week: Disability Income Protection
CMA members have two weeks left to sign up for guaranteed-issue disability income protection from Hartford Life and Accident Insurance Company. No health statements or medical exams are required. All you need to do is fill out a simple enrollment form and pay your premium. This year’s open enrollment period ends June 30.
Physician members age 59 or younger actively practicing full time (30+ hours a week) are eligible and will not be turned down for any reason. Members under age 50 receive a long-term disability benefit of $1,500/month for up to two years and a business overhead benefit of $1,500/month for up to one year. Members age 50 to 59 get a disability benefit of $1,000/month for up to two years and a business overhead benefit of $1,500/month for up to one year.
Both offers are subject to preexisting conditions limitations. Call Marsh Affinity Group Services at 800/842-3761 for details.
Click here for more information about the benefits and discounts available to CMA members.
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