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1. Blue Cross Backs Off Some Planned Fee Schedule Changes
As previously reported in CMA Alert, Blue Cross of California recently notified physicians of changes to its Prudent Buyer fee schedule. According to a notice mailed to physicians, the insurer plans to modify payment levels for many CPT codes, some being increased and others decreased. As you know, Blue Cross delayed implementation of its new fee schedule, originally scheduled to take effect June 1, because of outrage from CMA and the physician community over the insurer’s failure to provide physicians with timely access to the new fee schedule. The new implementation date is August 30.
CMA this week learned that Blue Cross has reconsidered some of the planned fee schedule reductions and has decided to leave some codes unchanged. Affected are some breast biopsy, breast mammography, colonoscopy, and newborn care codes. (Click here for a full list of affected codes.)
Blue Cross will soon post an update on its website and each affected physician will receive a notice from the insurer. The notice will include a link to the updated fee schedule where all changes will be reflected. In the meantime, you can view new rates here. (After you log in, click on “What’s New” then “Request Pricing.”)
Physicians are urged to calculate the impact of the fee schedule changes on their practices before it takes effect August 30. You should also be aware that you have the right to terminate an agreement if any “material change” to the contract terms is not acceptable to your practice.
CMA has published a Blue Cross of California Survival Kit to help you assess the impact fee schedule changes would have on your practice based on your most commonly billed CPT codes. The tool kit, available free to CMA members, answers frequently asked questions and discusses the options for physicians who determine that the new contract terms would negatively impact their practices.
Click here for more information.
CMA’s Reimbursement Help Line, 888/401-5911 gfonseca@cmanet.org.
2. Most California Physicians Eligible for Blue Shield Settlement,
Despite Blue Shield of California ’s Refusal to Participate
As reported last month in CMA Alert, Blue Shield of California refused to settle a class-action lawsuit filed in 2003 that would have meant tens of millions of dollars to California physicians. This lawsuit alleged that Blue Shield’s payment practices defrauded physicians out of monies due for patient care. Blue Shield of California is one of the few Blue Shield companies of nearly 40 licensees in the nation that has refused to settle this case and pay doctors the money they are owed.
Even though Blue Shield of California chose not to participate in this settlement, all class members, including most California physicians, are eligible for one or more shares of the $130 million settlement. The class includes all physicians who billed any of the Blue Shield companies or their contracted intermediaries (capitated medical groups, IPAs, etc.) for services provided between May 22, 1999, and May 31, 2007.
The deadline to submit a claim is October 19. Physicians do not have to provide documentation for individual Blue Shield claims. To receive your share of the settlement, you need only calculate the aggregate payments received from the settling Blue Shield companies from 2004 to 2006. Claims submitted to Blue Shield of California should not be included in the calculations.
Because Blue Shield of California was unwilling to settle, most California physicians will only be entitled to one settlement share. Physicians who have treated a large number of out-of-state Blue Shield patients may be entitled to more.
Physicians with $5,000 or less in claims billed to the settling defendants are eligible for one pro rata share; those with $5,001 to $49,999 are entitled to five shares; and those with more than $50,000 will receive 10 shares. The share value will be determined once all claims have been received.
If Blue Shield of California had participated in the settlement, most California physicians would have received 10 pro rata shares.
The case, Rick Love, M.D. v. Blue Cross Blue Shield Association, was filed in May 2003 in federal district court in Miami. The suit accused the insurers of a pattern and practice of denying and delaying care, including intentionally programming computer billing databases to automatically downcode physician claims. The suit was filed under the federal civil racketeering (RICO) statutes. Although CMA is not a plaintiff in the suit, the suit affects all physicians because of its class-action status.
Click here for more information.
Contact: CMA’s reimbursement helpline at 888/401-5911 or gfonseca@cmanet.org.
3. DMHC Introduces New Regulations to Prohibit
Physicians from Billing Patients for Emergency Services
The Department of Managed Health Care last week filed new proposed regulations that would prevent noncontracted physicians from billing patients for emergency services. The regulations will officially be published by the Office of Administrative tomorrow. In August of 2006 DMHC proposed similar regulations but did not act on them.
In addition to prohibiting noncontracted and contracted physicians from billing enrollees for emergency services (except for copayments, coinsurance, and deductibles), the new proposal creates a voluntary independent dispute resolution process to resolve payment disputes; requires HMOs in the event of a payment dispute to pay physicians an interim amount of 150 percent of 2007 Medicare rates; and modifies the Gould criteria (the nationally accepted standard for determining fair and reasonable payment for health care services) to include Medicare and contract rates.
CMA still needs to analyze the regulations so that we can more precisely assess the scope of the proposal and develop appropriate strategies to deal with these regulations. Stay tuned to CMA Alert for more information.
Click here for more information.
Contact: Francisco Silva, 916/444-5532 or fsilva@cmanet.org.
4. Health Net RICO Settlement Checks Are in the Mail
Physicians who filed claims under the Health Net settlement will soon begin receiving their checks. The checks were mailed Friday, August 10.
The pro rata share of the $40 million settlement is $59.30. Physicians will be paid based on the total three-year volume of Health Net claims they submitted, as they indicated on the claim form they filed. Physicians with less than $5,000 in Health Net claims receive one share; those with $5,000 to $49,999 receive five shares; and those with $50,000 or greater receive 10 shares.
Of even greater significance is the settlement’s prospective relief, which is valued at more than $80 million. Health Net has made a binding commitment to change the way it does business with physicians and to put a stop to the underhanded business practices that were used to deny or delay payment to physicians for legitimate claims. These changes are expected to result in increased predictability and speed of claims payment, creating significant value for physicians by reducing time-consuming and costly administrative burdens.
This settlement is the direct result of CMA advocacy and demonstrates the tremendous strength of CMA and its membership. In a historic action six years ago, CMA filed a class action lawsuit against for-profit HMOs in California. Eventually, more than 800,000 physicians and 19 state and county medical associations joined CMA as plaintiffs. The civil racketeering (RICO) lawsuit alleged that the 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.
Of the 10 defendants named in the lawsuit, six have settled (including the merged Anthem/WellPoint/Blue Cross), and three had their cases dismissed by the court. The dismissal of the cases against United Healthcare and Coventry have been appealed.
It is essential that the plans abide by the terms of the settlements. CMA encourages physicians to help ensure these plans keep their promises. If you believe that a health plan is not living up to the terms of its settlement, please contact CMA at 800/786-4CMA (4262).
Click here for more information.
5. Physicians Urged to Meet with Federal Lawmakers
to Discuss Medicare Payment Reform
CMA encourages physicians to meet with their federal lawmakers to discuss the Medicare/Healthy Families legislation that will be taken up by a joint House/Senate conference committee when Congress reconvenes in September. This legislation is critical to preserving access to care in California. Federal lawmakers are in their home districts this month during Congress’s summer recess.
The U.S. House earlier this month passed a bill that would stop the 15 percent physician pay cut and institute .5 percent payment increases for the next two years. It would also update California’s geographic payment localities and prevent any geographic payment reductions for three years. Additionally, it would reauthorize the Healthy Families program.
The Senate, however, passed a scaled-down version of the House bill, without the Medicare provisions. Because of this discrepancy, the physician payment reforms are at risk of being scaled back. It is important for physicians to make their congressional representatives understand that stopping the 15 percent payment cuts planned over the next two years is critical to preserving access to care for Medicare patients.
Click here for more information.
Contact: Elizabeth McNeil, 415/882-5176 or emcneil@cmanet.org.
6. Deadline to Resubmit Previously Denied Claims
for CAD Mammography to CIGNA is December 1
CIGNA earlier this year agreed to pay previously denied claims with add-on codes for computer-aided digital (CAD) mammography originally submitted between January 1 and October 10, 2004. Claims can be resubmitted from June 1 to December 1.
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. 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 became effective January 1, 2004, but CIGNA did not begin paying those claims until October 10, 2004.
Click here for more information.
Contact: CMA's member service center, 800/786-4CMA(4262) or info@cmanet.org.
7. Benefit of the Week: $105 Off Part B News from Decision Health
CMA members receive $105 off a subscription to Part B News, the largest independent source of news and guidance for Medicare Part B billing and reimbursement issues. Regular subscription rate for 48 weekly issues is $509, but as a CMA member you pay a discounted price of $404.
A members-only discount code is needed to take advantage of this discount. Visit CMA's members-only website or call the member service center at 800/786-4CMA (4262) to get your code.
Click here for more information on your membership benefits.
Contact: CMA's membership hotline, 800/786-4CMA (4262) or lgodward@cmanet.org.
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No. 2107
