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1. Blue Cross Physician Contract Inconsistent
with State Law and RICO Settlement
A CMA analysis of Blue Cross’s Prudent Buyer contract has found that it is inconsistent with state laws and regulations, including the Knox-Keene Act. The detailed analysis of the contract and its flaws is available to members at the members-only website. You can also find on the website objective written analyses of a dozen other major health plan contracts on the website.
The contract, among other things, gives Blue Cross the authority to unilaterally decrease contracted payment rates if a physician refers patients to out-of-network providers. This provision not only improperly obstructs the physician-patient relationship and interferes with PPO patients’ right to access out-of-network benefits, but is also a violation of California law, which requires insurers to give contracted physicians 45 days' notice of material changes to their contracts and an opportunity to terminate the contract if the new terms are not acceptable. Additionally, this provision is inconsistent with the RICO settlement, in which Blue Cross agreed to give 90 days’ notice of any material contract change.
CMA reminds physicians that before they sign a health plan contract, it is important to know what value that relationship will bring to their practice. Physicians do not have to accept contracts that are not mutually beneficial.
To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting tool kit, “Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations—A Focus on Payor Contracting.” The tool kit is available free to members at the members-only website. Nonmembers can purchase the tool kit for $100 in the CMA bookstore.
Click here for more information.
Contact: Aileen Wetzel, 916/551-2037 or awetzel@cmanet.org.
2. Unilateral Fee Schedule Changes by
Blue Cross Could Impact Patient Access to Care
Preliminary results from a CMA survey show that nearly a quarter of member physicians responding to the survey have terminated or plan to terminate their Blue Cross contracts over concern that the proposed new fee schedule would jeopardize the viability of their practices.
After Blue Cross announced fee schedule changes earlier this year, CMA began receiving a high volume of complaints from physicians regarding the proposed changes. To determine the impact the proposed fee schedule changes would have on California physicians and their patients, we surveyed our members for their reaction. Four hundred and ninety five practices responded, representing 1,566 physicians and over 91,000 Blue Cross patients in 31 different counties.
Final survey results will be issued next week.
CMA is working hard to address this and other Blue Cross issues. Earlier this summer we 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. CMA has also asked state insurance regulators to take action against Blue Cross for jeopardizing the physician-patient relationship and engaging in unlawful business practices that have reduced patient access to care. Stay tuned for more information.
Click here for more information.
Contact: Jodi Black, 916/551-2863 or jblack@cmanet.org.
3. Medicare Claims with NPI or Provider Type
Discrepancies Will Be Rejected Beginning Sept. 17
Beginning next week, California’s Medicare carrier will reject a claim if it is unable to match a physician’s legacy identifier (PIN) to his or her National Provider Identifier (NPI).
Physicians are encouraged to immediately check with their billing offices to determine what, if any, Medicare error codes have been returned over the summer. Such errors could indicate an NPI mismatch in the Medicare system. If you use a clearinghouse, check with it to ensure that these codes are not being stripped off of your claims.
Additionally, changes in the Medicare enrollment process over the years have caused some differences between the NPI and Medicare identification number assignment process. This may require some physicians to complete a new Medicare enrollment form so that their NPI and Medicare “provider types” match.
Particularly affected are solo incorporated practices, which are required to obtain both an organizational NPI and an individual NPI. If you have two NPIs but only one Medicare provider number, a new CMS 855 application may be necessary.
If you are not sure whether this applies to your practice, call California’s Medicare carrier NHIC for assistance at 877/527-6613.
Click here for more information
Contact: Frank Navarro, 916/551-2046 or fnavarro@cmanet.org.
4. Four CMA-Sponsored Bills Pass Legislature
Four of CMA’s sponsored bills passed the Legislature, and now await the governor’s signature. CMA also successfully averted a number of legislative attempts to ban balance billing and expand the scope of practice of allied health professionals. All of these bills stalled in committee and were tabled until next year.
CMA-sponsored bills on the governor's desk:
- AB 682, which would help make HIV testing a routine part of medical checkups.
- AB 632, which would strengthen whistle-blower protections for physicians and prohibit hospitals from retaliating or discriminating against a physician on its medical staff for speaking out about the quality of care provided in the facility.
- AB 1226, which would streamline Medi-Cal physician enrollment.
- AB 1324, which would confirm that it is illegal for insurers to rescind or modify authorization after services are rendered in good faith.
Two CMA-sponsored bills introduced this year will be taken up again in the next legislative session. These include the farmworker health coverage bill (AB 770), which would improve access to health care for farmworkers in California, and AB 1155, which would require mandatory penalties for HMOs that are found by the Department of Managed Health Care to have underpaid physicians, and would require those HMOs to automatically pay to physicians the full amount of underpayment plus interest.
With less than a week left in the current legislative session – and no agreement on health care reform in sight – the governor on Tuesday called a special session to hammer out a health care compromise. CMA is pleased that the governor and the Legislature are demonstrating a continued commitment to health care reform.
Click here for more information.
Contact: Susan Bassett, 916/444-5532 or sbassett@cmanet.org.
5. Security Prescription Orders Placed by Sept. 15
Guaranteed to Arrive by Federal Oct. 1 Deadline
The new federal Medicaid security prescription law will take effect October 1. Implementation will not be postponed.
To help ease the burden of this new requirement, especially for physicians with a high volume of Medi-Cal patients, CMA has negotiated a 20 percent member discount on tamper-proof pads that meet both federal and state security prescription requirements. Orders placed by September 15 are guaranteed to arrive by the federal implementation date of Oct. 1.
This special discount from CMA's security prescription partner RxSecurity is available through Wednesday, November 7.
Place your order online at http://www.rxsecurity.com/cma.php or by phone at 800/667-9723.
Click here for more information
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
6. There’s One More Day Left to Place Your Ad
in the CMA Foundation Annual Dinner Program
The CMA Foundation’s 2007 President’s Reception and Dinner Dance is October 28 at the Disneyland Hotel in Anaheim, during CMA’s annual meeting. Proceeds will support CMA Foundation, a charitable organization that links physicians and their communities to raise awareness about important public health issues, including appropriate antibiotic use, childhood obesity, diabetes, smoking cessation, and health disparities.
Honored at the dinner will be incoming CMA President Richard Frankenstein, M.D., and the foundation’s leadership award recipients, Condessa Curley, M.D. (Robert D. Sparks, M.D., Leadership Award), Kwabena Adubofour, M.D. (Adarsh S. Mahal, M.D. Access to Health Care and Disparities Award), and Edward Chow, M.D. (Ethnic Physician Leadership Award).
Tickets are on sale now. Individual tickets are $125, 10-person tables are $850. Even if you will not be able to attend, consider placing an ad in the dinner program to recognize Dr. Frankenstein, your organization, the leadership award recipients, or even a colleague or loved one. It's up to you! The foundation is a nonprofit charitable organization, and all ads are tax deductible. The ad deadline is September 14.
Visit http://www.calmedfoundation.org for more information.
Contact: Liz Burdick, 916/551-2886 or lburdick@cmanet.org.
7. Member Benefit of the Week: 20% off Security Prescriptions
For a limited time, CMA members get an extra 5 percent (for a total of 20 percent) off tamper-proof pads that meet both federal and state security prescription requirements. This special discount from RxSecurity is available through Wednesday, November 7.
Place your order online at http://www.rxsecurity.com/cma.php or by phone at 800/667-9723.
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. 2110
