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1. Blue Shield Planning to Publish Physician Ratings Based on Faulty CPPI Data
The California Cooperative Healthcare Reporting Initiative (CCHRI) is operating a quality reporting pilot project called the California Physician Performance Initiative (CPPI). Over the past two years, CPPI has used claims data from private PPO patients from Anthem Blue Cross, Blue Shield, and United Healthcare to measure physicians on a set of quality measures.
CMA continues to have serious concerns with the validity and accuracy of the data that has been collected. Results of CCHRI’s own reconsideration process in 2009 found significant inaccuracies, with 33 percent of physician scores being overturned during the reconsideration process.
CMA also surveyed members who completed the reconsideration process and found similar results. Because the CPPI program relies solely on claims data, it fails to comprehensively document the care a patient receives or the reasons why a patient may not receive the care that is the focus of a quality measure. For example, one physician reported that he was marked down for not recommending cervical cancer screening to patients who had undergone hysterectomies. Another physician was penalized for a procedure that he recommended, but that was subsequently denied by the HMO for medical necessity.
Many organizations have voiced similar concern with the validity of the CPPI data, including county medical associations, major physician groups, the University of California at San Diego, and CCHRI’s own physician advisory group (PAG).
Despite the recommendation from CCHRI’s physician advisory group not to release the faulty data, Blue Shield has indicated that it will likely publish the results. At this point, Blue Cross and United have not said whether they will publish the 2009 CPPI results.
CMA has learned that Blue Shield is planning to give digital “blue ribbons” to physicians who scored in the top 50th percentile, and will possibly reopen the reconsideration process for physicians who are interested in improving their scores. Blue Shield has tentative plans to publish this information by the end of December.
CMA is very concerned about the implications of making this data public, given the serious concerns about its accuracy. Even a “partial” publication of the results, as is being planned by Blue Shield, is problematic given the faulty data used to score physicians. It also infers that some physicians are not quality doctors because they did not receive a “blue ribbon.”
CMA continues to work to dissuade payors from publishing the 2009 CPPI results, and to persuade CCHRI to fix the flaws in the CPPI data gathering process before moving forward with the project.
Click here for more information.
Contact: Armand Feliciano, 916/551-2552 or afeliciano@cmanet.org.
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2. U.S. House Introduces Bill that Would Exempt Small Health Care Organizations from Red Flags Rule
The Federal Trade Commission (FTC) recently announced it would again delay enforcement of its new Red Flags Rule, which requires “creditors” – including physicians – to develop and implement identity theft detection and prevention programs. The new regulations are now scheduled to take effect on June 1, 2010. This is the third time the FTC has delayed implementation.
Several factors appear to be causing these delays, including objections from CMA and others in organized medicine, as well as objections from other professionals, such as accountants and attorneys. In fact, the American Bar Association recently won a lawsuit in federal court holding that the Red Flags Rule could not be applied to attorneys. It is possible this decision may have an impact the FTC’s decision to apply the Red Flags Rule to physicians.
Congress also has reviewed the scope of the rule and has recently introduced a bill (HR 3763) that would create an exemption for health organizations, including physician practices, with 20 or fewer employees.
For more information, see CMA’s updated Red Flags Rule toolkit, available free to members, at the members-only website.
Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.
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3. Are Your Payors in Good Financial Health?
One of the symptoms of an insolvent health plan, IPA, or other payor is a failure to pay claims in a timely manner. Another indication of financial distress is a payor that cuts checks within the statutory timeframes but does not release the checks in a timely manner. If you are experiencing repeated payment delays you should investigate the financial health of the payor.
To help physicians monitor the financial health of their contracted payors, CMA has put together the following checklist.
1. Check the financial solvency reports on the DMHC’s website.
- The Department of Managed Health Care (DMHC) is required to collect and analyze the financial statements of health plans and risk bearing organizations (RBOs) such as IPAs on a quarterly and annual basis. This allows DMHC to monitor their financial solvency.
- See the RBO financial solvency reports at tje DMHC website. For each payor, a designation of “met” or “not met” will be assigned for each grading criteria. The reports also indicate whether organizations that have “not met” any of the grading criteria have implemented correction action plans (CAP), and whether they are in compliance with the terms of the CAP.
- Health plan financial statements and the results of DMHC financial examinations can also be found at the DMHC website.
2. Verify receipt of claims with the payor.
- A few years ago, during the time of the devastating IPA bankruptcies in California, one of the ways payors avoided paying for claims was to routinely tell physicians that there was “no claim on file.” California law now requires health plans and their contracting medical groups and IPAs to acknowledge receipt of claims within 2 business days for electronic claims and within 15 days for paper claims.
- Confirming receipt of your claims with a payor, particularly a problem payor, allows you to quickly identify potential solvency issues and ensures your claims won’t be denied at a later date for failure to file them in a timely manner.
3. Appeal claims that haven’t been paid within the regulatory timeframe.
- State law requires that PPO claims be paid within 30 working days and HMO claims within 45 working days of receipt of a clean claim. There is a misconception that claims that haven’t been paid or denied can’t be appealed. If a plan or IPA has not paid your claim in a timely fashion, you can and should file an appeal based on lack of payment (a sample letter is available in CMA On-Call document #0124, “Late Payment”).
4. Call CMA’s reimbursement help line.
- If you are not successful with your appeal or believe the payor may be in trouble,
contact CMA’s reimbursement help line at 888/401-5911 or jwilliams2@cmanet.org.
5. File a complaint with the appropriate regulator.
- DMHC regulates all California HMOs, as well as Blue Cross and Blue Shield PPOs. File a complaint online with DMHC or call 877/525-1295.
- Most PPOs and other non-HMO insurers are regulated by the Department of Insurance (DOI). Even though DOI is not required to collect the same type of financial data from its regulated insurers, it is still important to notify them of any solvency concerns. File a complaint online with DOI or call 800/927-HELP (4357).
For more information, see CMA On Call documents #0223, “Risk-Bearing Medical Groups, Including IPAs: Regulation of Solvency,” #0131, “Insolvency of Health Plan, IPA or Other Entities that Contract with Health plans (Pre-Bankruptcy or Closure),” and #0106, “Bankruptcy of IPAs or Health Plans.” 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.
Contact: CMA’s reimbursement help line, 888/401-5911 or jwilliams2@cmanet.org.
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4. 2010 Medicare Payment Rule Cuts Physician Payments by 21.2%; Eliminates Payment for Consultations
The Centers for Medicare & Medicaid Service (CMS) recently released the final 2010 Medicare payment rule, which includes a 21.2 percent physician payment cut. The rule will be published in the Federal Register on November 165. Understandably, there is much concern in the physician community about what this will mean for their practices. CMA is working to pass a permanent SGR fix as part of the health reform package.
Repealing the SGR through the federal health reform package remains CMA’s top federal priority. Short-term fixes year after year have grown the problem. In four years the cost of a permanent solution has ballooned from $49 billion to more than $200 billion and the cuts physicians are facing have increased from under five percent to a whopping 21.2 percent.
CMS is also planning to implement a controversial change that would eliminate payments for all consultation codes other than the G codes that are used to bill for telehealth consultations, which would effectively cut payments to specialists. CMA and AMA are also seeking legislation or administrative action to stop this change. Although CMA fully supports increased payments for primary care, those increases cannot be paid for by cutting payments to other specialties.
CMS is still accepting comments on the 2010 physician payment rule. To submit comments, click here.
Click here for more information.
Contact: CMA’s reimbursement help line, 888/401-5911 or jwilliams2@cmanet.org.
5. U.S. House to Take Critical SGR Vote this Week; All Physicians Urged to Call
The US House of Representatives is poised to vote on HR 3961, a bill that would repeal the current Medicare Sustainable Growth Rate (SGR), the formula that threatens to cut Medicare payments to physicians each year.
HR 3961 would repeal the SGR, and with it more than $250 billion in projected Medicare physician payment cuts. The SGR would be replaced with two new spending targets, one for primary care and one for all other services. Physician payment rates under the new formula would track GDP plus automatic annual increases of approximately 2 percent for primary care services and 1 percent for all others. The new spending targets would be rebased every 5 years so that any future projected cuts will be eliminated. Congressional leaders have committed to work with organized medicine to develop a longer term fix to the fee schedule beyond the 1-2 percent updates in future years.
There are other Medicare payment reforms contained within the larger health reform bill, HR 3962, which was passed by the House in early November. These reforms include an additional 5 percent Medicare primary care increase and a California GPCI fix.
The House is scheduled to vote on HR 3961 as early as tomorrow, November 17. This is a very important vote for physicians and their patients. Every doctor must call to ensure a successful vote. The sheer number of physician phone calls will matter.
Contact your Representative today to urge them to vote yes on HR 3961. Congress must understand that fixing the Medicare SGR is an essential component of health reform. We must fix the SGR to ensure that seniors, military families, and the disabled have access to doctors in California.
To call your Representatives, please use the AMA Grassroots Hotline at (800) 833-6354. Plug in your zip code and it will automatically connect you to your Member of Congress. Calling your Representative is more effective at this point than e-mail, but click here to send an email to your Representative.
For more information, please see CMA’s Medicare SGR Issue Brief.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
6. Appeals Court Protects California’s Voter-Enacted Drug Treatment Program
A California Appeals court recently upheld a decision blocking a legislative attempt to radically alter Proposition 36, California’s landmark drug-treatment-instead-of-incarceration initiative.
Prop. 36, the Substance Abuse and Crime Prevention Act, was approved in 2000 by 61 percent of California voters. It reformed criminal sentencing laws by enrolling most nonviolent drug offenders in community-based treatment programs, rather than jailing them. In 2006, Governor Schwarzenegger signed into law Senate Bill 1137, which undermined Prop 36 by allowing judges to incarcerate people who suffer drug relapses during treatment.
In 2006, advocates filed a lawsuit to reverse SB 1137. CMA filed an amicus brief in this case, telling the court that SB 1137 would impermissibly alter the core medical and public health approach of Prop. 36 and thwart the effectiveness of rehabilitation and treatment programs favored by California voters when they passed Prop. 36.
SB 1137 would have also permitted courts, who are not medical professionals, to terminate or interrupt a treatment program due to a participant’s drug relapse. CMA opposed this bill when it was before the Legislature.
In 2006, the trial court invalidated SB 1137 because it both contradicts specific mandates of Prop. 36 and does not further the initiative’s purpose.
Click here for more information.
Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.
7. Blue Cross Extends Healthy Families Continuity of Care Plan
As you may recall, Blue Cross announced earlier this year that it would require physicians to sign a separate contract and accept reduced rates if they want to continue treating Blue Cross-insured Healthy Families and AIM patients. The new rates vary, but generally they are only slightly higher than Medi-Cal rates.
Although the effective date on the new contracts is September 1, the insurer had announced it would institute a continuity of care plan that would allow physicians with Prudent Buyer contracts to continue treating Blue Cross Healthy Families patients through at least the end of October. This week, Blue Cross notified physicians that it would extend the continuity of care plan through December 31. In lieu of a newly signed Healthy Families contract, physicians will be paid 125 percent of Medi-Cal for most Healthy Families services.
This extension comes on the heels of allegations that Blue Cross is failing to provide an adequate network of physicians to care for the nearly 3,400 Humboldt County children and expectant mothers enrolled in the insurers’ Healthy Families and AIM programs. CMA has filed a complaint with the Department of Managed Health Care (DMHC) urging them to look into the situation.
CMA believes the network inadequacy concerns can be traced back to Blue Cross’s Healthy Families recontracting initiative. Physicians have reported to CMA that the new rates do not cover the cost of providing medical care, leaving them no choice but to leave the Blue Cross Healthy Families network.
Physicians who have decided not to sign the new contract can refer patients to Blue Cross for help locating a participating provider. Healthy Families patients can call 800/845-3604, AIM patients 877/687-0549.
Click here for more information.
Contact: CMA’s reimbursement help line, 888/401-5911 or jblack@cmanet.org.
12. Featured Member Benefits
EHR Best Practice Series Webinars: To help members begin to assess their HIT needs, CMA has partnered with Maxwell IT to provide members with complimentary registration to the EHR Best Practices Series webinars. To register for an upcoming EHR webinar, please visit CMA’s HIT Resource Center, and click on “HIT Webinars.
Members can register FREE for both “How to Best Select an EHR” and “E-Prescribing Best Practices.” A members-only discount code is required to access this discount. Visit the members-only website or call CMA’s member help line (800/786-4CMA) to get the code.
For more information on these and other member benefits, visit http://www.cmanet.org/benefits or contact CMA at memberservice@cmanet.org or 800/786-4CMA.
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