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Top Story: CMA asks DMHC to investigate improper overpayment refund requests
The California Medical Association (CMA) has heard complaints from several physicians who have received overpayment refund requests from the Anthem Blue Cross Special Investigations Unit outside the 365-day period allowed by California law. As a result, CMA has filed a formal complaint with the Department of Managed Health Care and asked it to quickly investigate these potential violations. READ MORE
Also in this issue:
- Health insurer report card finds increasing inaccuracy in claims payment
- Groups come together to oppose dense breast notification bill
- Highlights from AMA's 2011 House of Delegates
- CMA President James G. Hinsdale, M.D., elected to serve on AMA Council on Medical Service
- Using the Internet to communicate with patients
- Volunteers needed for physician-student mentoring program
- CPPPH launches regional workshops for physician health committees
- CMA Foundation Obesity Prevention Project survey
- Seminar (7/27): Implementing OPPE and FPPE: A Skills Building Workshop
- Webinar (7/6): Collections – Get Paid Now!
- Webinar (6/29): Selecting the Right EHR for Your Practice
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. READ MORE
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1. CMA asks DMHC to investigate improper overpayment refund requests
The California Medical Association (CMA) has heard complaints from several physicians who have received overpayment refund requests from the Anthem Blue Cross Special Investigations Unit outside the 365-day period allowed by California law. As a result, CMA has filed a formal complaint with the Department of Managed Health Care (DMHC) and asked it to quickly investigate these potential violations.
State law allows health plans to pursue recovery of any type of overpayment made to providers within 365 days of the date the claim was paid. For claims older than 365 days, plans can seek to recover overpayments only if the alleged overpayment was "caused in whole or in part by fraud or misrepresentation on the part of the provider."
CMA believes that Blue Cross is using an overly broad definition of "misrepresentation" to seek recoupment on claims older than one year. The insurer appears to define "misrepresentation" as any untrue material fact or error, whether deceitfully or innocently made.
"Adopting Blue Cross's apparent construction of 'misrepresentation' to include inadvertent or reasonable mistakes would eviscerate the purpose of the recoupment laws and effectively nullify the 365-day limitation period," CMA wrote in a letter to DMHC. "That is because virtually any alleged overpayments can be described at least as a misrepresentation based on an inadvertent mistake. There would be no time limitation on a plan's overpayment demands, which is clearly contrary to the purpose and intent of the recoupment laws." DMHC has referred CMA's complaint to its Enforcement Division.
To help physicians understand their rights and options when it comes to health plan refund requests, CMA has published a "Special Investigations Unit Audit Guide." This document is available free to members in CMA's online resource library.
Contact: CMA's reimbursement help line, (888) 401-5911 or economicservices@cmanet.org.
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2. Health insurer report card finds increasing inaccuracy in claims payment
The nation's largest health insurers committed errors on nearly 20 percent of claims payments this year, up 2 percent from a year ago, according to the American Medical Association's (AMA) fourth annual National Health Insurer Report Card.
AMA said the increase in overall inaccuracy represents an extra $3.6 million in erroneous claims payments compared to last year. AMA estimates that eliminating health insurer claim payment errors would save $17 billion.
The AMA report card provides an annual assessment of how health insurers manage, process and pay claims. The findings are based on factors such as insurer non-payment to physicians, denials for medical treatment, prior authorization requirements, accurate contract fees to doctors and timeliness of claim payments.
UnitedHealthcare scored the best among the seven leading commercial health insurers with an accuracy rating of 90.23 percent, while Anthem Blue Cross Blue Shield scored the worst with an accuracy rating of 61.05 percent.
AMA launched the National Health Insurer Report Card in 2008 to stimulate improvements in health insurers' billing practices for physicians and patients.
Did you know?
The practice management experts in CMA's Center for Economic Services provide members with one-on-one help to identify, prevent and fight unfair payment practices. For more information, call CMA's reimbursement help line, (888) 401-8911, or email economicservices@cmanet.org.
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3. Groups come together to oppose dense breast notification bill
The California Medical Association (CMA) has joined with the American Congress of Obstetricians and Gynecologists – District IX, the California Radiological Society, the Medical Oncology Association of Southern California and the Association of Northern California Oncologists to oppose a bill that would require physicians notify mammography patients with highly dense breasts about the density of their breast tissue and the possibility that they may require additional imaging services (including ultrasound or MRI).
While the intent of the bill (SB 173) is to give women more power and control over their health, the legislation is vague and would impose undue cost burdens on the patient. Because high breast density is not currently by itself a risk factor for cancer in medical guidelines, in cases where prior authorization is required for additional screening, the tests may not be covered.
"This legislation outlines a course of action that is vague and in many cases, not necessary," said Ernie Bodai, M.D., director of Breast Surgical Services at Kaiser Permanente in Sacramento and creator of the breast cancer stamp. "Many of my colleagues and other major physician organizations have examined the intent, the science and the cost of this bill and find it to be lacking."
For the state to mandate that information be provided to patients, the information must be clear. While significant data has been gathered, there is not yet clarity on what "dense breasts" means and what should be done clinically. CMA doesn't believe it makes sense to mandate language that suggests women may need additional screening without this medical clarity.
"As part of the mammography report, the radiologist already reports density information to the referring physician," said CMA President James. G. Hinsdale, M.D. "The patient's physician should consider dense breasts as a factor along with other risk factors, such as age, history of breast cancer in family and prior mammograms."
Data is voluntarily being collected through the national American College of Radiology Breast Imaging Reporting and Data System system to enable data analysis so that it will become clearer about what actions should be taken in the case of high breast density. Once data is sufficient, professional medical guidelines will change to reflect this new information.
More information on this and other bills of interest to physicians is available at CMA's issues database.
Contact: Carolyn Ginno, (916) 551-2547 or cginno@cmanet.org.
4. Highlights from AMA's 2011 House of Delegates
The California delegation to the American Medical Association's (AMA) House of Delegates presented a number of important resolutions at the association's annual meeting in Chicago. The following are summaries of some of the resolutions that the AMA House adopted as policy.
Mercury Emissions (Res. 501): The delegates adopted a California resolution that asks AMA to support the Environmental Protection Agency's national mercury emissions standards for cement kilns at limits based on the latest pollution control technology.
Health Plan Coverage for Smoking Cessation (Res. 103): The delegates reaffirmed existing policy that asked AMA to support state legislation that would require health care service plan contracts to include coverage for tobacco cessation services, including counseling and both prescription and nonprescription medications approved by the FDA for tobacco cessation, without copayment, coinsurance or deductible.
Mental Health Care in Underrepresented Ethnic Populations (Res. 401): The delegates reaffirmed existing policy that asked AMA to support public health campaigns and partnerships between county departments of mental health and underserved ethnic communities.
Download an expanded summary of California resolutions from the AMA House of Delegates.
Related News: See "CMA President James G. Hinsdale, M.D. elected to serve on AMA Council on Medical Service."
Contact: Ginnie Yee, 415/882-5170 or gyee@cmanet.org.
5. CMA President James G. Hinsdale, M.D., elected to serve on AMA Council on Medical Service
At the American Medical Association's annual House of Delegates meeting in Chicago last week, James G. Hinsdale, M.D., president of the California Medical Association (CMA), was elected to the AMA Council on Medical Service.
The Council on Medical Service is one of seven AMA councils whose elected or appointed members make policy recommendations on issues such as ethics, science and medical education. The Council on Medical Service recommends AMA policies and actions for consideration by the AMA House of Delegates on the socioeconomic factors that influence the practice of medicine.
"This is a great honor. At a time when we need to be focusing on patient access to care and quality medical services, I am pleased to have been elected to the Council on Medical Service," said Dr. Hinsdale. "In California, we're facing serious cuts that would hugely affect access to care and the time that physicians are able to spend with their patients. Being part of the AMA council that recommends policy decisions is a job that I take very seriously and look forward to being part of."
Dr. Hinsdale is the director of trauma at Marin General Hospital and executive director of trauma at Regional Medical Center in San Jose. He is a board-certified surgeon and the founder and president of the Northern California Trauma Medical Group, which includes 18 practicing trauma surgeons.
Dr. Hinsdale joins former CMA President Robert Hertzka, M.D., on the council.
Contact: Molly Weedn, (916) 551-2069 or mweedn@cmanet.org.
6. Using the Internet to communicate with patients
As more patients access the Internet, physician websites can be an effective way to advertise and provide general information about your practice and the services you offer. However, physicians must be mindful of potential liability risks that may arise from giving medical advice online or via email.
CMA offers medical-legal document #0823 "Physician Websites, Internet Advice and Email" to help physicians understand these risks.
As the document explains, the legal elements of a professional liability lawsuit against a physician giving advice via an Internet site will not differ significantly from a suit in which a patient was treated in person (i.e., the patient will try to prove that there was a physician-patient relationship, that the treatment/advice was negligent and that the negligence caused the patient's injuries). Potential ways to reduce the likelihood that one might be sued for professional negligence in conjunction with a physician website or advice given via email include the use of disclaimer statements, website privacy policies and email policies.
The document also offers a summary of a physician's responsibilities as they relate to protecting patient confidentiality. Physicians who maintain a website or social networking account, or who give advice over the Internet or by email must comply with all federal and state privacy and security laws.
Medical-legal document #0823, "Physician Websites, Internet Advice and Email," as well as the rest of the CMA medical-legal library (formerly CMA On-Call), is available free to members at 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.
7. Volunteers needed for physician-student mentoring program
The eXchange Learning (XL) Mentor Program, sponsored by the California Medical Association (CMA) Ethnic Medical Organization Section, is seeking physician volunteers to serve as mentors for the 2011-2012 academic year. The XL program matches physicians with one or more compatible medical students from their county based on common professional and personal interests. Physician mentors practicing primary care are especially needed, as XL hopes to strengthen the primary care physician pipeline by targeting medical students working toward this specialty.
Physician mentors will guide medical students through the challenging process of becoming successful California physicians and will foster supportive relationships to encourage their mentees to reach their full potential. Throughout the year, mentors will be encouraged to meet both formally and informally with their student mentees at sponsored events, lunch meetings, office shadow visits, recreational activities, etc.
CMA will be pairing physicians and students in August. Physicians interested in serving as mentors for the 2011-2012 academic year should contact CMA by July 30, 2011, to be enrolled.
Contact: Veronica Ramirez, (916) 551-2887, vramirez@cmanet.org.
8. CPPPH launches regional workshops for physician health committees
California Public Protection and Physician Health, Inc. (CPPPH) is launching regional educational workshops on physician well-being for hospital medical staff committees and others involved in physician health activities.
The first workshop will be Saturday, July 9, 2011, at the Alameda Contra Costa Medical Association (ACCMA) for physician health committees in Alameda, Contra Costa, Marin and San Francisco Counties. Presenters will include medical leaders and legal experts in the field of physician health. Workshop topics will include:
- An overview of physician health in California
- Committee roles, responsibilities and functions
- Identifying and sharing resources and developing a regional network
CPPPH is offering this workshop to hospital medical staffs, medical groups, specialty societies and county medical associations. Attendance is by invitation only and is limited to members of physician health committees. There is no cost to attend, but advance registration is required. To register, please email cppphinc@gmail.com.
For information on future workshops, or if you are interested in bringing a workshop to your area, contact CPPPH at cppphinc@gmail.com.
CPPPH was established in 2009 as an independent nonprofit corporation dedicated to developing a statewide physician health program to respond to the needs articulated by physician health committees. CPPPH is funded by the California Medical Association and its component societies, the California Hospital Association, California's specialty societies and medical liability insurance carriers, and individual donors.
Contact: Gail Jara, cppphinc@gmail.com.
9. CMA Foundation Obesity Prevention Project survey
The California Medical Association (CMA) Foundation Obesity Prevention Project is working to update our Child and Adolescent Obesity Provider Toolkit. If you've used any of our clinical toolkits, we'd like to hear from you!
Please take a few minutes to participate in this quick survey and let us know how the CMA Foundation can provide resources that focus on key messages and issues that are important to California health care professionals.
This survey should take less than 10 minutes to complete and all responses will be kept confidential. Upon full completion of this survey, participants will be given an opportunity to enter a drawing to win one of five $25 Starbucks gift cards.
Contact: Vanessa Saetern, (916) 779-6631 or vsaetern@thecmafoundation.org.
10. Seminar (7/27): Implementing OPPE and FPPE: A Skills Building Workshop
The California Medical Association's Institute for Medical Quality (IMQ) is introducing a new one-day educational workshop to help physician leaders and staff effectively improve performance measurement, credentialing and privileging activities. "Implementing OPPE and FPPE: A Skills Building Workshop" focuses on the skills necessary to identify professional practice trends that impact quality of care, to collect organization data that is relevant, and to link Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE) data with individual physician performance.
This workshop presents a shared learning opportunity for teams of medical staff leaders and professional staff responsible for their organization's quality improvement, credentialing and privileging processes. The workshop takes place on Wednesday, July 27, 2011, at the California Endowment's Oakland Conference Center.
A discount is offered for CMA members and for additional participants from the same organization. For more information, or to register, visit the IMQ website.
Contact: Leslie Anne Iacopi, (415) 882-5167 or liacopi@imq.org.
11. Webinar (7/6): Collections – Get Paid Now!
Today's health care providers depend on medical billing collections to keep practices profitable and patient-friendly. In all too many practices, however, collection activities take a back seat to myriad other daily office activities.
This webinar, presented by Mary Jean Sage of The Sage Associates, will cover effective collection techniques and what to do when collection efforts fail.
The one-hour webinar will be presented twice on July 6, 2011, at 12:15 p.m. and again at 6:15 p.m. To register, visit the CMA event calendar.
Contact: CMA member help center, (800) 786-4262 or memberservice@cmanet.org.
12. Webinar (6/29): Selecting the Right EHR for Your Practice
This webinar, part of CMA's electronic health records (EHR) webinar series, will guide physician practices through the process of selecting an EHR system, including things to consider before you get started. This webinar is intended for practices in the very early stages of the EHR selection process.
The one-hour webinar will be presented twice on June 29, 2011, at 12:15 p.m. and again at 6:15 p.m. For more information or to register, visit the CMA event calendar.
Contact: CMA member help center, (800) 786-4262 or memberservice@cmanet.org.
13. 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. For more information, call (866) 941-1477 or visit the Heartland website.
For more information on these and other member benefits, click here or contact CMA at memberservice@cmanet.org or (800) 786-4262 (4CMA).