1. Deadline to Change Medicare Participation Status Is Dec. 31
Physicians who wish to change their Medicare participation status for 2007 must do so by December 31. Physicians can change their Medicare status between participating and nonparticipating only during Medicare’s annual open enrollment period. A participating physician must accept Medicare allowed charges as payment in full for all their Medicare patients. A nonparticipating provider can choose to accept or not accept assignment on Medicare claims on a claim-by-claim basis. Once made, Medicare participation decisions are binding for the entire year.
Physicians may also choose to opt out of the Medicare program entirely. Physicians who opt out of Medicare are bound only by their private contracts with their patients (although Medicare specifies that these contracts contain certain terms). You may choose to opt out at any point in the year, but once you opt out, you cannot opt back in for two years.
CMA also encourages physicians to review any of private payor contracts that tie their payment rates to Medicare
As reported last week in CMA Alert, most physicians are facing Medicare payment cuts in 2007, with some California physicians seeing cuts of 14 percent. These cuts are a combined result of the 5 percent sustainable growth rate (SGR) cut and changes in work relative value units (RVUs) stemming from the recently completed five-year review.
The new work values place a stronger emphasis on primary care, with significant increases to the values for evaluation and management (E&M) services, including pre- and postoperative surgical care. The new work values are based on recommendations made by the AMA/Specialty Society RVS Update Committee.
These new work values will increase spending for E&M services by $4 billion next year. However, federal budget neutrality requirements forced CMS to apply a 5.5 percent reduction to all services. As a result, only four specialties will see net increases in 2007: infectious disease (+4%), emergency medicine (+2%), pulmonary disease (+1%), and endocrinology (+1%).
“While significant E&M increases were called for and supported by most specialties, balancing the budget on the backs of physicians is unacceptable,” says CMA president Anmol S. Mahal, M.D. “We need to seek a long-term formula that pays physicians based on actual practice costs.”
Although physicians should continue to aggressively lobby Congress to stop these cuts, it there is no guarantee Congress will act before January 1. Recognizing that Congress’s failure to stop the Medicare rate cut may affect physicians’ Medicare participation decisions, CMA encourages physicians to read CMA ON-CALL document #0151, “Medicare Participation (and Nonparticipation) Options.” ON-CALL documents are free to members at the members-only website. Nonmembers can purchase ON-CALL documents for $2 per page in the CMA bookstore.
If Congress fails to act during the lame duck session, it may possibly pass legislation in late January as it did last year, to retroactively reverse the cuts. If Congress does act in early 2007, past experience suggests that the provider enrollment period will be reopened to give physicians an opportunity to modify their participation status based on the latest fee schedule.
Click here for more information, including a side-by-side comparison of 2006 and 2007 payment rates by CPT code.
Contact: Reimbursement Help Line, 888/401-5911.
2. Highlights from AMA’s Interim Meeting Available Online
The California delegation to AMA’s House of Delegates presented a number of important resolutions—on subjects ranging from silent PPOs to medical care for undocumented patients to the Medicare geographic payment localities—at the association’s interim meeting this week in Las Vegas.
Click here for summaries of the resolutions that the AMA House adopted as policy.
Contact: Ginnie Yee, 415/882-5170 or gyee@cmanet.org.
3. Wellpoint RICO Settlement Checks Are in the Mail
Physicians who filed claims under the Wellpoint/Anthem settlement will soon begin receiving their checks. The pro rata share of the settlement is $174 for active physicians and $284 for retired physicians. Physicians will be paid based on the total three-year volume of Wellpoint/Anthem claims they submitted, as they indicated on the claim form they filed last fall. Physicians with less than $5,000 in Wellpoint/Anthem claims receive one share; those with $5,000 to $49,999 receive five shares; and those with $50,000 or greater receive ten shares.
Of even greater significance is the settlement’s prospective relief, which is valued at more than $250 million. Wellpoint/Anthem 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.
Click here for more information.
Contact: CMA’s legal information line, 415/882-5144 or legalinfo@cmanet.org.
4. Quality Matters: Policy Analysts Concerned About Rush to Adopt P4P
The rush to adopt pay-for-performance programs has raised a number of concerns among physicians and policy analysts. In the November 2, 2006, issue of the New England Journal of Medicine (NEJM), Dartmouth Medical School professor Elliott Fisher, M.D., discusses the recent Institute of Medicine (IOM) report, “Rewarding Provider Performance: Aligning Incentives in Medicare.” The report, which was highlighted last month in CMA Alert’s “Quality Matters,” is the third in a series of quality improvement studies requested by Congress.
Dr. Fisher, a member of the IOM committee that produced the report, is critical of current work in performance measurement. “Unfortunately, much of the current work...seems to ignore one or more of the commonsense principles outlined by the IOM committee,” writes Dr. Fisher in the NEJM article. “The technical quality measures still reflect a tiny segment of clinical practice. The efficiency measures used or under discussion target discrete diagnoses and episodes (which can make fragmented care by multiple providers appear ‘efficient’), rather than the longitudinal costs and outcomes of care (which would reward comprehensive, coordinated care by single providers).”
In light of these shortcomings, Dr. Fisher says that it is critical that the “peformance” of any Medicare pay-for-performance program itself be measured so that officials and experts can identify and correct the inevitable mistakes that will be made.
Dr. Fisher also discusses the challenges of pay-for-performance participation for small office practices and the need for additional funding,
Click here for more information, including a link to the NEJM article.
Contact: Sandra Bressler, 415/882-5171 or sbressler@cmanet.org.
5. CMA Radiologist Receives Kaiser's Exceptional Contribution Award
Oakland radiologist K.M. Tan, M.D., recently received Kaiser Permanente’s 2006 Exceptional Contribution Award for cofounding in 1989 the Kaiser Permanente School of Radiology Technology. The award is given annually to a physician who proves “instrumental in the development and dissemination of new ideas that have a significant impact on patients, colleagues, and the broader community.”
The school, today called the KP School of Allied Health Services is now one of the most successful community outreach and vocational training schools in California, and provides training in a variety of areas, including sonography, nuclear medicine, radiation therapy, and phlebotomy.
Dr. Tan, chief of radiology at Kaiser Permanente Medical Center in San Rafael, is the immediate past chair of the Institute for Medical Quality board and is current chair of Audio Digest’s CME committee.
Click here for more information.
Contact: Diana Ly, 415/882-5151 or dly@cmanet.org.
6. There’s Still Time to Register for CMA’s Last
Pain Management Conference Before CME Deadline
California law (AB 487) requires physicians to complete 12 hours of continuing medical education (CME) in pain management and the care of terminally ill and dying patients. Physicians have until December 31 to satisfy this requirement.
One way to fulfill the requirement is by attending CMA’s pain management conference, “Pain, Palliation, & Politics: Pain Management and End-of-Life Care in California’s Regulatory Environment.” This practical two-day CME program will be offered December 1-2 at the Disneyland Hotel in Anaheim. CMA tailored this program to meet the needs of physicians who do not specialize in pain medicine.
Members pay $335 (nonmembers $600).
Click here for more information.
Contact: CMA’s seminar line, 415/882-3330 or kdefabrique@cmanet.org.
7. CMA Member Benefit of the Week: HIT Information
CMA has partnered with KLAS Enterprises to provide user satisfaction data on health care information technology (HIT) products to members at a significant discount. Some of KLAS’s data is available free to members. All that’s required is that you share with KLAS your practice’s experience with at least one of your current software vendors by filling out a 40-question survey.
KLAS is a Utah-based company that compiles comprehensive data on HIT products, including electronic medical record, transcription, billing and scheduling, and other office systems. All KLAS ratings are based on user surveys. The data allows physicians to evaluate HIT products based on the experience of physician users and other professionals to help them select the best products for their practices.
Click here for more information on KLAS.
Click here for more details about your CMA member benefits and discounts.
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No. 2071
