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1. Congress Approves Stopgap Measure to Delay Medicare Cuts
Both houses of Congress approved a measure that would delay the deep Medicare cuts scheduled to take effect on January 1. The cuts, prescribed by Medicare’s flawed funding formula known as the Sustainable Growth Rate (SGR), would slash payments to doctors by 21 percent.
The delay, approved as part of a $636 billion defense appropriations bill, would postpone the effective date of the physician payment cut until March 2010. We anticipate that the President will sign this bill in the coming days.
It remains CMA's goal to incorporate a long-term SGR fix into the federal health reform legislation.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
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2. Medicare Participation Decision Deadline
Extended to January 31, 2010
In light of the uncertainty surrounding the SGR and health reform, the Center for Medicare and Medicaid Services has extended the deadline for providers to determine their Medicare participation status for 2010.
Physicians who wish to change their participation status for 2010 will now have until January 31, 2010, to do so. The effective date of the decision will be January 1, 2010, retroactively if necessary. Participation decisions are binding for one year, unless physicians choose to opt-out entirely. Once you opt out, you cannot opt back in for two years.
Physicians, as always, have three choices regarding Medicare: be a participating provider; be a nonparticipating provider; or opt out of Medicare entirely.
A participating physician must accept Medicare allowed charges as payment in full for all Medicare patients.
A nonparticipating provider can choose to accept or not accept assignment on Medicare claims on a claim-by-claim basis. Nonparticipating physician fees are 95 percent of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25 percent more than the amounts allowed in the participating physician fee schedule.
Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare’s limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract.
For more information on physicians' Medicare participation options, see CMA On-Call document #0151, "Medicare Participation (and Nonparticipation) Options." On-Call documents are free to members. Nonmembers can purchase On-Call documents for $2 per page at the CMA Bookstore.
Contact: Michele Kelly, 714/634-3908 or mkelly@cmanet.org.
3. CMS Eliminates Medicare Consult Codes
Despite objections from CMA and others in organized medicine, the Centers for Medicare & Medicaid Services last week decided to move forward with its controversial plan to eliminate payments for inpatient and outpatient consultation codes and require physicians to instead bill for either new or established office visits or for initial hospital stays. Effective, Jan. 1, 2010, consult codes (99241-99255) will no longer be recognized for Medicare Part B payment.
Although the payment rule will provide minor increases in payments for some inpatient and outpatient E&M visits to offset losses that will result from the elimination of these codes, physicians asked to provide expert opinions will could see an 8 percent reduction or more in reimbursement as a result of this new policy.
Although CMS's decision was intended to alleviate confusion that has surrounded the reporting of these codes for years, the new policy will likely cause additional confusion as physicians and billing managers try and make sense of the new rules.
To help physicians understand what this means for their practices, CMA has scheduled a members-only webinar with Palmetto Medical Director Arthur Lurvey, M.D. Dr. Lurvey will answer physician questions and explain how to bill for these services in 2010 and beyond.
The one hour webinar is this Wednesday, December 23, at 12:30 pm. You can register here. Registration is free, but space is limited, so reserve your space today.
Contact: Michele Kelly, 714/634-3908 or mkelly@cmanet.org.
4. Senate Pushing for Health Reform Vote Before Christmas
Senate Democratic leaders reached agreement over the weekend with holdout Nebraska Senator Ben Nelson, paving the way for a vote on the Senate health reform legislation on Christmas Eve. To get Nelson’s vote, Senate leaders offered a compromise on abortion coverage and agreed to permanently fund the proposed Medicaid expansion, but only for Nebraska. CMA will be analyzing the final Senate bill as details are released and will provide a summary in the coming days.
Senate Democrats must still navigate a series of procedural votes to make the Christmas Eve deadline, but we anticipate they will be able to pass both the procedural votes and the substantive reform bill itself.
If the Senate successfully passes a health reform bill, a joint House-Senate conference committee would meet to reconcile the House and Senate bills. It is CMA’s goal and hope to be able to support the legislation that comes out of the conference committee, known as the conference committee report. The report must then be ratified by both houses of Congress before going to the President for his signature.
As you may know, CMA has taken an oppose position on the Senate bill as it currently stands. At its fundamental level, our opposition is based on the failure of the Senate bill to improve access to care for Californians. For more details on CMA's position, visit CMA's Health Reform page for a copy of our letter to Senators Diane Feinstein and Barbara Boxer on the issue.
CMA physician leaders and staff have from day one been engaged with our Representatives and Senators, working towards health reform that fixes what is broken in our system and keeps what works. We are hopeful that through these efforts and those of organized medicine across the country that we are able to help produce meaningful health reform legislation from the conference committee that works for doctors and patients.
See CMA's Health Reform page for more information.
Contact: Elizabeth McNeil, 415/882-3376 or emcneil@cmanet.org.
5. State Proposes Sweeping Changes to Medi-Cal Program
The state Legislature recently held public hearings on a Department of Health Care Services' concept paper that contemplates significant changes to the Medi-Cal program, with the goal of providing patients with access to better coordinated care that will improve outcomes and help slow the long-term growth in program costs.
The concept paper, which contains no specific details, is the first step in the process of renewing – and expanding – California's Section 1115 Medicaid waiver. (Under the federal Medicaid program, certain laws and rules can be waived to grant states greater program flexibility.)
The proposal calls for shifting the most vulnerable enrollees (nearly all of the population of children and adults with disabilities, the blind, mental health needs and seniors) out of the fee-for-service program into an "organized delivery systems of care," such as managed care or medical homes.
CMA submitted comments on the proposal, telling DHCS that the physicians of California strongly support the idea of developing a model for patient-centered medical homes in the Medi-Cal program. However, CMA made it clear that any new treatment models must be carefully constructed so as not to overburden safety net physicians.
"Persistently low Medi-Cal reimbursement rates have forced many physicians to reduce or eliminate their Medi-Cal patient loads, and those physicians who continue to actively treat Medi-Cal recipients often serve very large patient panels, on very tight financial margins," CMA wrote in the comments. "Any new requirements on these physicians without an increase in resources available, will force many of these safety net providers out of the program."
CMA also told DHCS that only a physician should lead a medical home. While nurse practitioners and other allied health professionals play a crucial role in the health care delivery system, only a physician has the training and experience to properly coordinate patient care, particularly the high-risk patients that would be most impacted by this proposal.
Additionally, CMA expressed concerns that forcing patients into managed care might disrupt existing physician-patient relationships, and negatively impact access to care. CMA urged DHS to address these concerns by involving physicians in any local health system planning.
"Physician input in the process of establishing the treatment protocols for Medi-Cal Managed Care is essential," CMA wrote. "Physicians are often a patient's primary connection to the health care system, and they have a unique perspective on their patient's needs. While managed care can work well for some patients, one size does not fit all."
CMA also expressed significant concern over the program's pitifully low reimbursement rates. In many cases, the reimbursement does not even cover the cost of providing care. A number of legislators also echoed CMA's concerns.
"I really don't believe you can continue to ask the providers to pay for the privilege of treating Medi-Cal patients," said Senator Dave Cox, a member of the Senate Health Committee. "There comes a point in time when the physician is just simply going to say thank you very much, I will not pay to treat your patients and I think we are rapidly approaching that particular situation in the state of California."
CMA will continue to participate in the discussion and planning as the 1115 waiver proposal is fleshed out over the coming months.
Click here for more information.
Contact: David Ford, 916/551-2554 or dford@cmanet.org.
6. Judge Rules Rescission Lawsuit
Against Blue Cross Can Proceed
A state appeals court sided with CMA and the Los Angeles Medical Association (LACMA) in a decision that has cleared the way for a lawsuit against Blue Cross of California for illegally cancelling health care coverage for patients after they got gravely sick.
The ruling means a lawsuit filed by the Los Angeles city attorney can move forward in its pursuit of civil penalties, injunctive relief, and monetary restitution for patients and providers.
The court rejected the idea that the Department of Managed Health Care (DMHC) has exclusive jurisdiction to enforce violations of the Knox-Keene Act, as Blue Cross argued.
CMA and LACMA filed an amicus brief in August supporting the Los Angeles city attorney's case. At issue was whether public prosecutors, acting on behalf of private citizens, have the right to sue insurers for violations of state law or if the DMHC has exclusive jurisdiction to enforce violations of the Knox-Keene Act. The DMHC has repeatedly failed to enforce the Knox-Keene Act against HMOs, leaving it up to others to hold insurers accountable.
In 2008, the Los Angeles city attorney filed a lawsuit on behalf of the people of California against Blue Cross for false advertising and unfair business practices. The suit alleges that Blue Cross sold people false promises of coverage while systematically cancelling policies after patients got sick and filed expensive claims. This practice is known as rescission.
A congressional investigation last June found that WellPoint Inc., the parent company of Blue Cross of California, and two other insurers saved more than $300 million over five years by rescinding coverage for 20,000 people.
Over the past two years, CMA has sponsored legislation that would have required insurers to continue coverage until an independent board could review proposed rescissions and determine whether they were legal. Although the Legislature passed the bills with strong bipartisan support, Governor Schwarzenegger vetoed the bills.
Click here for more information.
Contact: Samantha Pellon, 916/551-2872 or spellon@cmanet.org.
7. Has Your IPA or Health Plan Stopped Paying Claims?
CMA has recently received calls from physicians concerned that some of the entities with whom they contract may have run into financial difficulties. 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 a checklist available to members. You can also request a hard copy by contacting CMA using the information below.
Contact: CMA’s reimbursement help line, 888/401-5911 or jwilliams2@cmanet.org.
8. Save the Date: 2010 California Health Care
Leadership Academy Is April 9-11 in San Diego
CMA's 13th Annual California Health Care Leadership Academy will be April 9-11 in San Diego. This year's conference, "The Era of Health Reform: Harnessing the Currents," will assess the status and impact of federal health reform efforts, including provider payment incentives that may change the organizational forms of medical practice.
The 2010 Academy will also feature three main breakout tracks: health information technology, leadership skills development, and practice management.
Registration will open in mid-to-late January. Stay tuned for more information.
Contact: Roger Purdy, 916/551-2067 or rpurdy@cmanet.org.
9. 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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