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Top Story: Blue Cross required to pay health care providers money owed to them, dating back to 2007
On January 12, the California Department of Managed Health Care ordered Anthem Blue Cross to pay health care providers money owed to them, with interest, for services provided dating back to 2007. The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims.
Also in this issue:
- California's congressional delegation is in for a shakeup
- Take the CMA survey about Medicare audits
- Blue Shield launches recontracting initiative
- Medi-Cal program successfully closes out transition
- Physician volunteers needed for CMA mentoring program
- Minor consent: What physicians need to know when treating children
- April 17, 2012: Save the Date for CMA's annual Legislative Leadership Conference
- Grim cancer statistics prompt CMA to call on physicians to talk with patients about free screenings
- HIPAA privacy and security training resource now available to non-members
- Upcoming webinars:
Featured member benefit:
Heartland Payment Systems: Members receive exclusive discounts and a three-year rate guarantee on Heartland Payment Systems’ suite of financial services, which includes credit card processing, payroll services, check management and real-time health benefits eligibility verification.
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1. Blue Cross required to pay health care providers money owed to them, dating back to 2007
On January 12, the California Department of Managed Health Care (DMHC) ordered Anthem Blue Cross to pay health care providers money owed to them, with interest, for services provided dating back to 2007. The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims.
California Medical Association (CMA) President James T. Hay, M.D., applauded DMHC for their recent announcement. “We provide necessary care to our patients based on the assumption that the health plans will promptly and accurately reimburse us for services rendered,” Dr. Hay said. “Anthem Blue Cross’s refusal to pay for a mistake on their end puts an undue burden on those of us who provide care.”
In 2008, DMHC launched provider claims audits of the seven largest health plans in California due to a growing pattern of complaints from providers regarding late and inaccurate payments and inappropriate claim denials. These audits found claims payment violations above the threshold allowed under California law at all seven health plans.
In response to the audits, DMHC required the plans to pay providers the money they were owed and to demonstrate improvements to the plans’ claims processes to prevent future errors. In addition, each plan entered into settlement agreements to pay administrative fines. To date, six of the seven plans have undertaken provider remediation efforts.
Anthem has refused to pay providers for the claims violations uncovered in the audit. Now, Anthem Blue Cross has 30 days to submit to DMHC a corrective action plan to identify the claims that were not correctly paid and pay the providers as prescribed by law.
Center for Economic Services helps physicians recoup money denied by payors
CMA’s Center for Economic Services (CES) provides one-on-one assistance to physician members and their staff for reimbursement and practice operations issues. For the second year in a row, CES has recouped more than $2.7 million from payors on behalf of its members. The center’s reimbursement help line has fielded over 2,600 calls about billing and contracting issues from more than 1,200 different physician practices.
“The work that the Center for Economic Services does at CMA is phenomenal for physicians who are facing difficulties with payors, but they can only do so much. The decision by DMHC to move forward and require Anthem to pay health care providers what they are owed is a huge relief, especially when Medicare and Medi-Cal programs are being cut,” Dr. Hay added.
For a full copy of the DMHC press release, please visit their website.
Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
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2. California's congressional delegation is in for a shakeup
Highlights
- Redistricting will change California’s Congressional delegation in 2012
- Pundits predict nine newcomers in the next Congress
- California Supreme Court to weigh in on redistricting in face of Republican-backed referendum
California, which has the largest congressional delegation in the country (53 members), will see big changes in 2012 as the direct result of redistricting and the public’s low approval ratings of Congress. Pundits are predicting at least nine newcomers in the next Congress.
These changes may also dilute some of California's power in Washington, D.C., as a few long-term politicians, with decades of seniority that have gained them positions of power, may be gone.
The biggest change in the political landscape will take place in long-time GOP strongholds in Southern California where newly redrawn districts will include citizens more inclined to the liberal side of politics.
Bowing out of national politics
Rep. Elton Gallegly (R-Simi Valley) announced his retirement January 7, after redistricting put him in competition against Rep. Buck McKeon (R-Santa Clarita), chairman of the House Armed Services Committee. Gallegly, 67, helped found Simi Valley and was once its mayor.
On January 12, Rep. Jerry Lewis (R-Redlands) announce his retirement from Congress after new boundaries drawn through redistricting promised to make the road to re-election more difficult. He is the longest-serving Republican member of Congress in California history, and the first Californian to chair the Appropriations Committee.
Rep. Wally Herger (R-Chico) announced his retirement January 9, ending more than three decades representing the Sacramento Valley in Congress and the state Legislature. He was the Chair of the powerful Ways and Means Health Subcommittee.
Three Democrats have also announced their retirements: Lynn Woolsey, who represented Marin and Sonoma counties for 19 years; five-term Rep. Dennis Cardoza of Merced County, who faced a race against San Joaquin Valley colleague Jim Costa; and Bob Filner, who has decided to run for mayor of San Diego.
In what is expected to be a tough race, two Democrats, Reps. Howard Berman and Brad Sherman, will face off against one another in Los Angeles.
Speculation is also rife that Rep. David Dreier (R-San Dimas), chair of the House Rules Committee, which determines what amendments are allowed on legislation, may be next. Dreier faces a heavily Democratic new district.
Challenge to redistricting
A challenge to redistricting in the form of a ballot referendum is causing headaches for the California judiciary. The Republican-backed group Fairness and Accountability in Redistricting (FAIR) has been canvassing for signatures for its referendum, which would kill the Senate maps drawn by the Citizens Redistricting Commission and is likely to qualify for the ballot in the fall. In the meantime, state Senate candidates must file for the June primary, while the California Supreme Court is struggling with the technical aspects surrounding the spring elections.
The justices held an inquiry on January 10 and questioned attorneys for the redistricting commission, the secretary of state’s office and FAIR about options if the court intervenes. A decision by the court is expected this month.
If the referendum qualifies for the ballot, the current maps could be "stayed," or placed on hold pending the November election.
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3. Take the CMA survey about Medicare audits
The California Medical Association (CMA) has posted a survey to find out how the Medicare audits are affecting physician practices.
On December 3, 2011, CMA President James T. Hay, M.D., sent a letter to the Centers for Medicare & Medicaid Services (CMS) regarding the multitude of medical review records requested of physicians by Palmetto, the Medicare administrative contractor for California. In the letter, Dr. Hay expressed members’ concerns about the volume of requests and the tone of the audit letters. In addition, Palmetto is also delaying payment to physicians for claims associated with the medical records and threatening physicians with further action.
If your office has received requests for medical records from Palmetto, please let us know the impact by taking a moment to complete a brief survey. The results will assist us in our discussion points with CMS. The deadline for completion of the survey is February 3, 2012.
CMA continues to work with Palmetto and CMS so they understand the burden of locating, copying and mailing off the requested patient records.
Upcoming webinar on E&M audits
On January 25, from 12:15 to 2 p.m., CMA is hosting a free member webinar on Medicare E&M Audits. Learn about Evaluation and Management documentation recommendations in light of the development of electronic health records, forms and pre-printed sheets. Attendees will also learn about examples of documentation that were found during recent Palmetto GBA Medicare audits and review, as well as how to select levels of E&M coding based on both CPT guidelines AND reasonable and necessary considerations for the clinical visit. Attendees will also have the opportunity to ask individual questions during an extended Q&A time period for answers to unique situations. To register for this special extended webinar, click here.
Contact: Michele Kelly, (213) 226-0338 or economicservices@cmanet.org.
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4. Blue Shield launches recontracting initiative
The California Medical Association (CMA) has learned that Blue Shield is in the process of recontracting with physicians across the state. Notices to physicians are scheduled to be mailed on January 27. Blue Shield states the reason for the recontracting initiative is twofold: 1) Blue Shield has not done a large scale recontracting with physicians in over a decade, so the new contracts will allow Blue Shield to ensure consistency and compliance with new laws and regulations; and 2) Blue Shield will be offering various tiered networks based on price point in anticipation of California’s health insurance exchange, a key feature of the federal health reform law. Physicians are under no obligation to participate in any of these products. There are no fee schedule changes at this time, other than for Medicare lines of business.
While the new contract will eventually be rolled out statewide, the first phase focuses on the following counties:
| Alameda | Mariposa | San Joaquin |
| Alpine | Mono | San Mateo |
| Amador | Monterey | Santa Barbara |
| Calaveras | Napa | Santa Clara |
| Colusa | Placer | Santa Cruz |
| Contra Costa | Plumas | Solano |
| El Dorado | Riverside | Sutter |
| Lake | San Benito | Tehama |
| Lassen | San Bernardino | Tulare |
| Marin | San Francisco | Yuba |
Physicians in Fresno County received the new contract in July 2011.
The cover letter that will accompany the new contract asks that physicians review, sign and return the new agreement to Blue Shield by February 17. However, Blue Shield has assured CMA that failure to return the new agreement will not affect a physician’s participation status with Blue Shield.
To assist physicians, CMA has completed an analysis of the new Blue Shield contract, which is available to CMA members at www.cmanet.org/ces. Physicians are encouraged to carefully review and understand the vast range of legal and practical implications associated with the execution of any contract for the delivery of medical services or the associated management and administrative services.
For additional information on evaluating and negotiating complex managed care contracts, see CMA’s contracting toolkit, Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations – A Focus on Payor Contracting.
Physicians with concerns about the new contract terms are encouraged to contact Blue Shield Provider Services at (800) 258-3091.
Contact: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
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5. Medi-Cal program successfully closes out transition
In October 2011, the California Department of Health Care Services (DHCS) transitioned to Affiliated Computer Services (ACS) as the new fiscal intermediary for the Medi-Cal program. This transition, which will be completed on January 31, 2012, was the largest and one of the most complex in the nation.
The focus was to move operations from the previous contractor to ACS with minimal impact to physicians and patients. One of the greatest challenges was the amount and volume of inherited suspended claims. Over the last few months, ACS, with DHCS oversight, has continued to make significant progress toward resolving this issue. After starting with a volume of 1.8 million suspense claims in October 2011, ACS has lowered that volume by more than 30 percent with the implementation of an aggressive and effective mitigation strategy.
ACS anticipates the claims suspense volume to be lowered by another nearly 30 percent by mid-February 2012, achieving optimal operating status.
The California Medical Association (CMA) worked closely with DHCS and ACS to reduce negative effects of the transition, and appreciates DHCS’s recognition of the impacts to Medi-Cal physicians during this transition period, and for its pursuit of every possible remediation of suspended claims.
CMA looks forward to a continued partnership between DHCS and ACS to ensure the perspective and concerns of physicians are considered as we seek to improve the Medi-Cal program. CMA members are encouraged to call the reimbursement helpline with any issues.
Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
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6. Physician volunteers needed for CMA mentoring program
Application deadline is February 1, 2012.
The eXchange Learning (XL) Mentor Program, sponsored by the California Medical Association (CMA) Ethnic Medical Organization Section (EMOS), is currently seeking physicians to serve as mentors.
Now in its second round of pairing, the XL Mentor Program seeks to match physicians with medical students from across the state based on their common and professional interests. While mentors practicing primary care are in particularly high demand – as the XL program hopes to increase the number of medical students working toward this specialty – physicians from all specialties are encouraged to apply.
Through the XL program, mentors will guide medical students through the process of becoming California physicians, offering advice and practical knowledge through a variety of different methods. The program’s vision is that both mentors and students will gain invaluable insight into the rewards and challenges of each other’s professional lives. Mentors will be encouraged to engage their mentees through both official and non-official interactions, including CMA-sponsored events, social media, lunch meetings, office shadowing and other activities.
The application deadline for those hoping to become an XL mentor is February 1, 2012, with official pairings set to take place in the following weeks. Mentors and mentees will kick off their new pairing at the annual California Health Care Leadership Academy, held from April 27-29 in Anaheim. A specific event for XL participants is planned.
Those interested in becoming a mentor through the XL program can find the application here.
Contact: Scott Clark, (916) 551-2887, sclark@cmanet.org.
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7. Minor consent: What physicians need to know when treating children
California law authorizes parents or guardians of minor children (anyone under the age of 18) to give informed consent for most medical decisions. However, there are some exceptions to this. Minors can consent to certain types of medical treatment under two types of statutes: status-based and treatment-based.
The California Medical Association’s (CMA) medical-legal document #0425, "Minor Consent," summarizes these statutes and other pertinent issues that physicians should be aware of prior to treating a minor. For instance, minors who are authorized to give legal consent to most medical treatment under the status-based statutes include married (or divorced) minors, minors on active duty with the U.S. Armed Forces, minors emancipated by a court order and self-sufficient minors (minors 15 years or older living away from home and managing their own financial affairs).
This member resource also includes information on what to do if the minor has adoptive, unmarried or divorced parents; parents who disagree about medical treatment; or legal guardians or caregivers. Medical record confidentiality is also discussed. It also includes sample forms that cover an individual authorized to consent to a minor's medical treatment and an affidavit for a minor caregiver's authorization.
An example of treatment-based consent for minors includes a new law that went into effect on January 1, 2012. Minors 12 years of age and older are now able to consent to preventive care, in addition to diagnosis or treatment of, sexually transmitted diseases without the consent of a parent or legal guardian. This would include hepatitis B and human papillomavirus (HPV) vaccines.
Medical-legal document #0425, "Minor Consent," as well as the rest of CMA's medical-legal library is free to members in CMA's online resource library. Nonmembers can purchase medical-legal documents for $2 per page.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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8. April 17, 2012: Save the Date for CMA's annual Legislative Leadership Conference
When: 9:30 a.m. to 5 p.m.
Where: Sacramento Convention Center
1400 J Street, Sacramento
The California Medical Association (CMA) is pleased to announce that California Attorney General Kamala Harris will be the keynote speaker for the 2012 Legislative Leadership Conference, to be held April 17. Members have the unique opportunity to join more than 400 physicians, medical students and CMA Alliance members who come to Sacramento to lobby their legislative leaders as champions for medicine and their patients.
The morning includes speeches from a number of key legislative leaders. Attendees will go to the Capitol in the afternoon to meet with legislators on health care issues. The meetings will be scheduled and coordinated by local county medical societies. Medical students will be scheduled to meet with elected state officials, including the Governor, Lieutenant Governor and Insurance Commissioner.
Photo Shoot
There will be a large group photo shoot with all the conference attendees on the west steps of the Capitol at 1 p.m. Please bring your white coats for the photo.
Health Fair
A health fair on the north steps of the Capitol is another feature of CMA Legislative Day. Physicians with a wide range of specialties will provide services and information to legislators and their staffs.
Capitol Museum
For the first time, CMA and the Sierra Sacramento Medical Society have obtained permission to display medical artifacts from Sierra Sacramento’s Medical History Museum in the Capitol Rotunda from April 16-20.
Legislative Day is offered at no cost to physicians. Please contact your local county medical society before making travel arrangements. Otherwise, expenses will be the obligation of each individual participant.
Registration is free for medical students, and scholarships may be available to medical students for travel and accommodations through their county medical societies.
CMA is currently in the process of scheduling additional speakers and will keep you posted as the agenda is finalized. More information about legislative meetings, afternoon events and the health fair will be coming your way shortly.
Medical Student Information
CMA will host a special advocacy training session for medical students with CEO Dustin Corcoran from 8:15 to 9:15 a.m. Medical students will once again have a special afternoon schedule, separate from the regularly scheduled physician legislative meetings.
Hotel Details
CMA has again established a local rate agreement with the Sheraton Grand Sacramento for 2012. You may book a room there for the discounted rate of $159. Online reservation instructions are available here. Reservations can also be made by calling (800) 325-3535 or (916) 447-1700 – ask for the California Medical Association corporate rate.
Register now!
Contact: Nick Birtcil, (916) 551-2570 or keycontacts@cmanet.org.
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9. Grim cancer statistics prompt CMA to call on physicians to talk with patients about free screenings
The American Cancer Society projects that in 2012, over 25,000 new cases of breast cancer and roughly 1,450 new cases of cervical cancer will be diagnosed in California alone. In light of these grim statistics, the California Medical Association (CMA) encourages physicians to help eligible patients take advantage of screening services offered by the state’s Every Woman Counts program.
This free program offers clinical breast exams, mammograms, pelvic exams and Pap tests to underserved women throughout California.
Despite its obvious value, this program has struggled for funding in recent years and was even closed to new enrollment for six months in 2010. Governor Brown’s recently released 2012-13 state budget also assumes a $14 million reduction for the programs, due to projections of lower patient enrollment.
These lower caseload projections are a major reason for the proposed reduction, as fewer women have joined the program since it re-opened in 2011, largely because they are unaware that it is available and actively enrolling new participants.
CMA urges all physicians to talk to their patients about Every Woman Counts so that we can help to reverse this unfortunate trend. If more women are made aware of EWC and acquire services through the program, the proposed cut may be retracted and more lives can be saved.
In order to be eligible for the screening services offered by the Every Woman Counts program, patients must meet a variety of income and eligibility requirements, including a lack of coverage from their insurance provider for screening services.
A complete list of the program’s requirements is available here.
Those who qualify are encouraged to call the California Department of Public Health at (800) 511-2300 to be referred to a participating physician in their area. Program representatives may also be able to refer women to other low-cost screening options, should they not qualify for the Every Woman Counts program.
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10. HIPAA privacy and security training resource now available to non-members
HIPAA mandates that all medical office staff (including physicians) be trained on the HIPAA privacy rules, security policies and procedures. The HIPAA Privacy and Security Rule Training Manual is now available to non-members. This manual provides a general training and overview and can be used as a part of your HIPAA training program. The manual contains:
- HIPAA Privacy and Security Rule Quiz
- Customizable checklist detailing the specific privacy and security rule responsibilities of the employee
- Employee certification form
The HIPAA Privacy and Security Rule Training Manual is a joint effort by the California Medical Association (CMA) and PrivaPlan® Associates, Inc.
For members the manual is free. The cost for non-members is $15. The manual is available in CMA's resource library.
Another resource for HIPAA compliance is the CMA/PrivaPlan HIPAA Privacy and Security Compliance Toolkit. The toolkit is customized for California law and contains customized forms, policies and procedures to ensure HIPAA compliance.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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11. Upcoming webinars
1/25: Medicare E&M Audits: Learn about Evaluation and Management documentation recommendations in light of the development of electronic health records, forms and pre-printed sheets. Attendees will also learn about examples of documentation that were found during recent Palmetto GBA Medicare audits and review, as well as how to select levels of E&M coding based on both CPT guidelines AND reasonable and necessary considerations for the clinical visit. Attendees will also have the opportunity to ask individual questions during an extended Q&A time period for answers to unique situations. This special extended webinar will take place Wednesday, January 25, 2012, from 12:15 to 2 p.m.
2/1: Key Financial Ratios to Increase Profitability: Today’s physicians and office managers need business management skills, particularly in the financial area. These are simple math ratios and essential to benchmark your practice to compared to “best practices” in your specialty. This workshop will teach critical skills in analyzing the practice profit/loss statement for overhead expense, accounts receivable and staffing ratios, and how to access specialty comparison norms for benchmarking. The one-hour webinar will take place Wednesday, February 1, 2012, at 12:15 p.m.
2/15: HIPAA Risk Analysis for Meaningful Use: Be sure you are able to qualify for your electronic health record (EHR) incentive funding! Conducting a HIPAA Security Risk Analysis for most medical practices is a core Meaningful Use measure (relating to one of the 15 core objectives). This webinar provides detailed instruction on the steps needed to complete a risk analysis and practical solutions for even the smallest medical practice.
Contact: CMA's member help center, (800) 786-4262 or memberservice@cmanet.org.
12. Featured member benefits:
Heartland Payment Systems: Members receive exclusive discounts and a three-year rate guarantee on Heartland Payment Systems’ suite of financial services, which includes credit card processing, payroll services, check management and real-time health benefits eligibility verification. For more information, call (866) 941-1477 or visit www.heartlandpaymentsystems.com.
For more information on your membership benefits, visit www.cmanet.org/benefits or contact CMA’s member help center at (800) 786-4262 or memberservice@cmanet.org.