A weekly newsletter for members of the California Medical Association
Serious Medicare Payment Problems Persist
The transition from NHIC to Palmetto is causing serious problems for California physicians. CMA is receiving a very high number of complaints from members who have not received payment for Medicare claims submitted both before and after the transition.
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1. Serious Medicare Payment Problems Persist
The transition from NHIC to Palmetto is causing serious problems for California physicians. CMA is receiving a very high number of complaints from members who have not received payment for Medicare claims submitted both before and after the transition. Several members have been forced to access credit lines to meet payroll and business expenses, and we are now hearing from physicians who are fearful that the situation may cost them their practice. While CMA has been very successful in getting resolution for physicians who contact our Center for Economic Services, doctors who are going directly to Palmetto for assistance are finding it impossible to get through on their phone lines. Practices that do get through are facing wait times of as much as three hours.
CMA has compiled a list of common problems and fixes and posted it online at http://www.cmanet.org/palmetto. Physicians who are still experiencing payment problems are encouraged to review this list to see if their issues are addressed. If after doing so you still have questions or problems, please contact CMA’s Reimbursement Help Line for assistance.
CMA continues to work with Palmetto and Center for Medicare & Medicaid Services (CMS) on a global fix of the situation. We have also secured commitments from many Congressional offices to intervene in the situation.
As reported in the last Alert, CMS authorized Palmetto to add 35 additional staffed phone lines. These phone lines should be active today. Palmetto has also indicated it will add an additional 15 phone lines later this week that will be dedicated to provider enrollment issues.
Contact: CMA’s Reimbursement Help Line, 888/401-5911.
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2. You’re Invited to a Medicare Payment Workshop in Sacramento, Friday October 3 at 6pm
Palmetto Coding Experts Will Answer Individual Physician Questions
All physicians and practice managers are invited to attend a special Medicare payment workshop hosted by CMA and presented by Palmetto GBA. Attendees will hear a 1 hour presentation, after which two Palmetto coding experts will be on hand to answer individual physician questions and help resolve any Medicare payment issues. Also in attendance will be Arthur
Lurvey, M.D., Palmetto’s J1 medical director and Mike Barlow, Palmetto vice president and J1 director.
The workshop is Friday, October 3 at 6pm in the Big Sur A/B Room at the Hyatt Regency in Sacramento. There is no cost and registration is not required.
3. CMA Takes Legal Action to Stop Unlawful DMHC Regulation
On Friday, September 26, CMA and a coalition of health care providers filed a petition with the Superior Court of California in Sacramento seeking an injunction against a regulation recently finalized by the Department of Managed Health Care (DMHC). The regulation expands the definition of “unfair billing pattern” to include a practice commonly known as “balance billing,” which DMHC asserts would provide it with the authority to bring enforcement actions against providers.
“Balance billing” occurs when HMOs refuse to pay in full for emergency services provided to their policyholders by doctors or hospitals with whom the insurance companies do not contract. Faced with the refusal by a giant financial corporation to pay the bill, providers are forced to send part of the bill to the patients to whom they provided the emergency care in order to recoup their costs.
HMOs make hundreds of millions of dollars shorting the health care providers who take care of Californians in need of emergency care through these denials.
CMA’s legal petition argues that the regulation is unlawful and unenforceable for the following reasons.
DMHC lacks the authority to regulate doctors. DMHC was created in order to protect Californians from health insurance companies, not allow insurance companies to underpay their policyholders’ bills, sticking them with the tab for emergency services.
The regulation runs counter to the Knox Keene Act’s intent to ensure that HMOs provide adequate networks of care for their policyholders. Instead of ensuring adequate provider networks for Californians with HMO plans, the regulation would shrink provider networks by transferring hundreds of millions of dollars from emergency services to insurance companies.
DMHC did not meet the procedural requirements of the Administrative Services Act, which require it to analyze the potential anticompetitive impacts of the regulation.
The Legislature, not DMHC, has the sole authority to regulate this issue.
The DMHC regulation takes effect on October 15. CMA anticipates that we will not receive resolution on our request for an injunction until a few weeks after that. To help physicians deal with the uncertainty caused by this regulation and to answer any questions they have about their rights and responsibilities under the regulation, CMA is preparing a provider toolkit, which will be available later this week. (A link will be placed under “CMA Spotlight” on the home page.)
Recently, the Centers for Medicare & Medicaid Services (CMS) notified state officials that it would shut down California’s Family PACT program on October 3 unless the state is able to meet new strict eligibility documentation rules.
Family PACT, which provides provide comprehensive family planning services and preventive health screenings to eligible low income men and women, has operated since 1999 under a Medicaid waiver that expires this month. According to the state, it has served 1.6 million Californians, prevented 170,000 unintended pregnancies and saved the state and federal government over $1 billion annually. CMS recently notified the state that as a condition of renewal California must follow burdensome new eligibility and application requirements. CMA believes that the new rules will discourage low-income women from seeking family planning and prenatal care, ultimately increasing the costs to the state and federal government.
CMA and a coalition of patient and provider groups has urged Congress to extend the waiver until July 1, 2009, to allow time for California and CMS to work out their differences and continue this successful, cost-effective, patient-centered program.
If Congress does not extend the waiver, the state will lose more than $300 million in federal matching funds and many low-income women will lose access to these vital health care services.
Click here to read CMA's letter to CMS on this issue.
5. Governor Approves State Budget; Structural Problems Remain
Last week, after the longest delay in the state’s history, Governor Schwarzenegger finally signed the $145 billion state budget.
While hospitals, clinics, nursing homes and other institutional providers will finally receive long overdue Medi-Cal payments, the budget did not achieve any meaningful structural budget reform. Instead of long term solutions, the spending plan is held together by temporary revenue gimmicks and questionable fiscal assumptions that will exacerbate problems in future years.
Health Care Cuts
Thanks to ongoing legislative and legal efforts by CMA and other provider groups, this budget eliminates almost all of the health care cuts proposed by the Governor in January. Rather than cutting over $2 billion from health care as originally proposed, this budget cuts $165 million.
Medi-Cal: CMA and other provider groups successfully petitioned the courts for a preliminary injunction to stop the 10 percent Medi-Cal reimbursement rate cuts that took effect July 1. As a result, claims with dates of service on or after August 18 will be paid at the full rate. Although the budget signed by the Governor does include a temporary 10 percent Medi-Cal provider rate cut through the end of February 2009, such a cut could only be implemented if the state successfully appeals the injunction. A 1 percent rate cut would remain going forward until stricken. Not all providers will receive the nearly full restoration. Pharmacists and long-term care facilities will only have 5 percent of the cuts restored on March 1.
The 2008-2009 budget also requires semi-annual eligibility checks for Medi-Cal patients, which is expected to save money due to a decrease in enrollment. Previously, eligibility was confirmed annually.
Public Health: Through his power to veto certain expenditures in the budget, the Governor cut roughly $10 million from public health programs. These cuts include a $3 million cut to teen pregnancy prevention programs, a $2 million cut to domestic violence programs, and a $1 million reduction to the childhood lead prevention program. The Department of Public Health has not yet determined exactly how these cuts will be implemented.
6. CMA's Annual House of Delegates Convenes this Weekend
At this year’s House of Delegates, physicians from across the state will debate and set policy on important health care issues including health system reform, universal health care, and health care information technology. The House of Delegates convenes October 4 to 6 in Sacramento.
During the three-day meeting, the 500 delegates will address more than 100 resolutions on these and other key issues that affect the practice of medicine. Dev GnanaDev, M.D., a San Bernardino County surgeon, will be installed as the association’s new president and the delegates will choose a president-elect.
CMA invites all members to visit its online forum by this Friday to discuss or comment on the resolutions and reports that will be considered by the delegates.
To participate in the online discussion, log in to the members-only website and click on House of Delegates Forum under CMA Spotlight. You do not need to register to read the resolutions or other members’ comments, but you will be required to register if you would like to reply or submit your own comments.
On Saturday, September 20, a number of CMA physicians participated in the 2nd Annual Well Being – Well Mind Community Health Fair in Los Angeles. The event, hosted by Assembly Speaker Karen Bass, included approximately 30 health booths and mobile testing units. CMA physicians performed free blood pressure checks, adult and pediatric wellness checks, and spoke one-on-one with attendees about the importance of preventive care and healthy lifestyles.
CMA looks forward to taking part in more community health events like this and has hired a Community Relations Director to work with doctors who want to get involved with their communities in a visible and helpful way.
If you are interested in participating in future community health events, contact Community Relations Director Amber Beck (contact information below).
Click here for more information, including more photos from the event.
8. Physicians Urged to Verify Accuracy of CPPI Quality Data
As previously reported in Alert, The California Cooperative Healthcare Reporting Initiative (CCHRI) is about to release quality data from its Medicare quality reporting pilot project called the California Physician Performance Initiative (CPPI). CPPI received federal funding in 2006 to develop a system for measuring and reporting the quality of health care provided by physicians. CCPI collected data on approximately 25,000 physicians for a limited set of nationally-endorsed quality measures for both Medicare patients and private PPO patients from Anthem Blue Cross, Blue Shield of California, United Healthcare.
CPPI was set to release data to affected California physicians last month. However, due to concerns raised by CMA, CCHRI and CMS agreed not to release the data until physicians were given the opportunity to verify its accuracy.
CCHRI has informed CMA that it beginning on October 15, it will confidentially release to each affected physician their individual quality measure scores based on patient care provided in 2006 and 2007. Physicians will be provided with a percentile rank compared to their physician peers, performance scores by measure, and performance scores for each patient group (Medicare only, private PPO only, and both Medicare and private PPO combined).
Physicians who would like to verify the accuracy of the data used to calculate their scores can request their private health plan patient lists at the CCHRI website. (Requests should be made via the “Physician Comment and Request for Information Period Process” available at http://www.cchri.org/cppi). Unfortunately, the Medicare patient lists will not be available to physicians for verification due to strict federal confidentiality and privacy laws. However, this also means that the physician-specific Medicare quality data will not at any time be released to the public by either Medicare or CCHRI. It must be destroyed.
Although CCHRI has no current plans to publicly release physician-specific quality scores related to the treatment of private PPO patients, it is possible that the plans could use this information in the future. However, the private health plans would only be allowed to review the scores of their network physicians. CMA will be working closely with CCHRI to vigilantly protect the use of physician information.
Stay tuned to the next issue of Alert for more details on the data reconsideration process.
9. Save the Date: CMA’s 34th Annual Legislative Leadership Conference Is April 14
Physicians seeking insight into and training on how to affect the political process are encouraged to clear their calendars so they can attend CMA’s 34th Annual Legislative Leadership Conference — aka “Doctor Day”— Tuesday, April 14 in Sacramento. Stay tuned to Alert for more details.
10. Member Benefit of the Week: 30 - 50% off Epocrates
CMA members receive 30 percent off one-year subscriptions and 35 percent off two-year subscriptions to any Epocrates product. Students and residents receive 50 percent off all Epocrates products. Group discounts are also available.
Epocrates provides physicians with point-of-care access (via PDA/smartphone, or online) to up-to-date information on drugs, diseases, and diagnostics. Epocrates allows physicians to make better clinical decisions, saving time and improving quality of care. To receive your discount, log in to the members-only website and follow the links to the Epocrates website.
Click here for more information on your membership benefits.
Contact: CMA’s member help line, 800/786-4CMA or vsatt@cmanet.org.
For previous editions of CMA Alert, visit our news archives.
Prepared by the CMA Communication Center
Katherine Gallia, Editor,
916/551-2074,
Patrick Harbison, Editorial Assistant
916/551-2072,
No. 2142
On Saturday, September 20, a number of CMA physicians participated in the 2nd Annual Well Being – Well Mind Community Health Fair in Los Angeles. The event, hosted by Assembly Speaker Karen Bass, included approximately 30 health booths and mobile testing units. CMA physicians performed free blood pressure checks, adult and pediatric wellness checks, and spoke one-on-one with attendees about the importance of preventive care and healthy lifestyles.
