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Top Story: CMA files lawsuit against DHCS and HHS over Medi-Cal reimbursement cuts
The California Medical Association joined with the California Dental Association, the California Pharmacists Association and the National Association of Chain Drug Stores to file a lawsuit against the California Department of Health Care Services (DHCS) and the U.S. Department of Health and Human Services (HHS). The suit is in response to the recent approval of a 10 percent reimbursement rate cut for Medi-Cal providers.
Also in this issue:
- CMA's Center for Economic Services recoups almost $3 million for members in 2011
- House and Senate pass bill to eliminate Medicare payment tax withholding
- HHS to award $1 billion in grants for health care innovations
- Highlights from AMA's 2011 House of Delegates
- 5010 Update: Enforcement delay presents challenges
- United Healthcare rolls out View360° program
- What the demise of the "super committee" means to California physicians
- AMA presents lifetime achievement award to William N. Guertin
- FAQ: Are you being investigated by the Medical Board?
- Reminder: Legislative rural caucus to hold two informational briefings
on the Medi-Cal experience - Upcoming webinars:
Featured member benefits:
Auto and Homeowners Insurance: CMA members receive 10 percent off auto insurance from Mercury Insurance.
Group Dental Program Open Enrollment: It’s open enrollment time for the Group Dental program. Applications must be received by December 31 for coverage in 2012.
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1. CMA files lawsuit against DHCS and HHS over Medi-Cal reimbursement cuts
The California Medical Association (CMA) joined with the California Dental Association, the California Pharmacists Association and the National Association of Chain Drug Stores to file a lawsuit against the California Department of Health Care Services (DHCS) and the U.S. Department of Health and Human Services (HHS). The suit is in response to the recent approval of a 10 percent reimbursement rate cut for Medi-Cal providers.
“In late September, CMS asked DHCS for more information that would substantiate their state plan amendments (SPAs) for cuts in the Medi-Cal program. Without receiving that information, CMS went ahead and approved the cuts,” said Francisco J. Silva, CMA General Counsel and Vice President. “It is clear that CMS did not follow protocol and applied the wrong legal standard. The approval of the SPAs will have dramatic effects on access to health care for the poorest, most vulnerable Californians.”
According to Silva, federal law requires that Medi-Cal patients have the same access to physicians and other health care providers as the general insured public. “CMA strongly believes that even before these cuts, California is in violation of federal access law,” he notes.
“Medi-Cal patients are already having a tough time getting access to care," says CMA President James T. Hay, M.D. "The approved cuts are irresponsible and will only put the health of California’s most vulnerable population further at risk. The federal government has made a terrible mistake in approving the cuts, especially in the face of health care reform. We simply cannot treat more patients with fewer resources.”
California's Medi-Cal rates are already almost the lowest in the nation. Currently, half the doctors in the state cannot afford to participate in the program. The gaping hole in California’s safety net will be further exacerbated by the 3 million uninsured newly eligible for Medi-Cal in 2014 under federal health reform legislation.
An independent study recently commissioned by CMA found that 49 percent of Medi-Cal patients are unable to get health care when they need it, compared to just 26 percent of privately insured patients.
What you can do
CMA and its member physicians want to make sure that Medi-Cal patients have access to health care. But we need your help. Contact CMA if you, your clinic or medical group can no longer afford to treat Medi-Cal patients, cannot find specialists who take Medi-Cal patients, or would otherwise be negatively impacted by the recent cuts that California made to the Medi-Cal program. You can also download a form to give to your patients to determine how they're being affected. You can help us in our efforts to reverse these cuts.
Contact: Michelle Rubalcava, (916) 551-2543 or mrubalcava@cmanet.org.
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2. CMA's Center for Economic Services recoups almost $3 million for members in 2011
For the second year in a row, the California Medical Association’s (CMA) Center for Economic Services (CES) has recouped more than $2.7 million from payors on behalf of its members. The center’s reimbursement help line has fielded almost 2,400 calls about billing and contracting issues from more than 1,200 different physician practices.
To date, CES has recouped $2,707,000 for member physicians – on its way to surpassing last year’s total of more than $2,780,000.
“Our goal is to empower practices by providing them self-help tools and teaching them how to be effective advocates for physicians and patients,” said Francisco Silva, CMA General Counsel and Vice President. “When the process fails, however, we’re always ready to intervene with the payor or regulator on the member’s behalf.”
Founded in 1999, CES provides members with one-on-one assistance for billing, contracting and payment problems that may arise. With more than 125 years of combined medical practice operations experience, CES staff helps members with issues ranging from underpayment or denials by payors to assisting with contract analysis during negotiations.
Assistance from CES can range from education on how to increase a practice’s efficiency to direct intervention with payors or regulators. This support is reserved exclusively for CMA members.
CES also provides members with access to CMA Practice Resources, a regular bulletin offering tips for improving practice efficiency and viability. To sign up for a free subscription, visit the CMA website at www.cmanet.org/newsletters.
For practical tools, newsletters and other online assistance, visit www.cmanet.org/ces.
Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
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3. House and Senate pass bill to eliminate Medicare payment tax withholding
On November 16, the U.S. House of Representatives passed an amended version of H.R. 674 that prevents a planned 3 percent tax withholding from physician reimbursement for the treatment of Medicare patients. The legislation, championed by the American Medical Association and the California Medical Association, was passed by a 422-0 vote. The Senate already passed this bill on November 10 by a vote of 95 to 0.
This represents a significant victory for physicians and a step forward in stabilizing the Medicare system. The additional burden of a 3 percent tax withholding would have been untenable in the current Medicare payment environment. Currently, there is an estimated 20 percent gap between Medicare’s payments to physicians and the growing cost of providing care. Physicians also face a 27.4 percent cut on January 1, 2012, due to the broken Medicare SGR physician payment formula.
The legislation, now headed to President Obama for his expected signature, completely repeals this provision of the law and eliminates the planned withholding.
Contact: Elizabeth McNeil, (415) 882-3376 or emcneil@cmanet.org.
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4. HHS to award $1 billion in grants for health care innovations
The Health Care Innovation Challenge, launched by the U.S. Department of Health and Human Services (HHS) on November 14, will award up to $1 billion for innovative projects that deliver better health, improved care at lower costs to patients enrolled in Medicare, Medicaid and the Children’s Health Insurance Program.
“Both public and private community organizations around the country are finding innovative solutions to improve our health care system, and the Health Care Innovation Challenge will help jump start these efforts,” said HHS Secretary Kathleen Sebelius.
Funded by the Affordable Care Act, the Health Care Innovation Challenge will award grants in March 2012 to applicants with the most compelling new ideas in health care delivery. The Challenge will support projects that can begin within six months. Additionally, projects that focus on rapid workforce development will be given priority when grants are awarded.
“When I visit communities across the country, I continually see innovative solutions at the very ground level – a large health system working with community partners to decrease the risk of diabetes with nutrition programs, or a church group that sends volunteers to help home-bound seniors so they can live at home,” said Donald M. Berwick, M.D., administrator of the Centers for Medicare & Medicaid Services.
Awards are expected to range from $1 million to $30 million over three years. Applications are open to providers, payors, local government, community-based organizations, with a particular focus on public-private partnerships and multi-payor approaches. Each project will be evaluated and monitored for measurable improvements in quality of care and savings generated.
CMA is working to submit several pilot program proposals to CMS for medical groups as well as independent solo/small group practice physicians based on models that have worked in California.
For more information, including a fact sheet and the funding opportunity announcement, see the Health Care Innovation Challenge initiative website at www.innovation.cms.gov.
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5. 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 AMA interim meeting in New Orleans. The following are summaries of some of the resolutions that the AMA House adopted as policy.
Truth and transparency in pregnancy counseling centers: Adopted a substitute resolution that asks the AMA to support that any entity offering crisis pregnancy services disclose information onsite, in advertising and before any services are provided about the medical services, contraception, termination of pregnancy or referral for services or adoption options. Advocate that any entity providing medical services to pregnant women that markets medical or any clinical services abide by licensing requirements, have the appropriate qualified licensed personnel and abide by federal health information privacy laws.
Addressing substance use and misuse in the United States: Adopted a substitute resolution that asks the AMA to promote physician training and competence on the proper use of controlled substances; encourage physicians to use screening tools; and provide references and resources for physicians so they identify and promote treatment.
Censorship of physician discussion of firearm risk: Adopted a California resolution that asks the AMA to oppose any restrictions on physicians being able to inquire and talk about firearm safety issues and risks with their patients, and oppose any law restricting physicians’ discussions with patients and their families about guns as an intrusion into medical privacy.
Generic vs. brand medications: Adopted a California resolution that asks the AMA to advocate to the Food and Drug Administration against removal of generic medications from the market in favor of more expensive brand name products based solely on a lack of studies of the efficacy of the generic drug.
Federal liability protection for EMTALA mandated care: Adopted as amended a California resolution that asks the AMA to support the extension of the Federal Tort Claims Act (FTCA) to all Emergency Medical Treatment and Labor Act (EMTALA) mandated care if an evaluation of a demonstration program, as called for in AMA Policy D-130.971(6), shows evidence that physicians would benefit by such extension. And, if an evaluation of a demonstration program shows evidence that physicians would benefit by extension of the FTCA, that the AMA conduct a legislative campaign, coordinated with national specialty societies, targeted toward extending FTCA protections to all EMTALA-mandated care. And that the AMA assign a high priority to this effort.
Download an expanded summary of California resolutions from the AMA House of Delegates here.
Contact: Ginnie Yee, (415) 882-5170 or gyee@cmanet.org.
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6. 5010 Update: Enforcement delay presents challenges
The effective implementation date of electronic transactions to the updated 5010 version of the Health Insurance Portability and Accountability Act (HIPAA) transactions standards is January 1, 2012. On that date, you are expected to conduct electronic transactions such as claims submissions, eligibility verification, claims status, remittance advice and referral authorizations using the updated transaction standards.
On November 17, 2011, the Centers for Medicare & Medicaid Services (CMS) Office of E-Health Standards and Services announced it would not initiate enforcement action against entities who had not adopted the new electronic transaction standards and codes until March 31, 2012. However, CMS has yet to instruct contractors how to respond to the enforcement extension for those who are not compliant. In order to avoid rejected claims and cash flow interruptions, practices should still plan on a January 1 implementation.
Each managed care plan will determine its own enforcement date. Practices are encouraged to contact their practice management system vendors, clearinghouse vendors and billing services to ensure they will be able to successfully implement the new standards prior to the compliance or enforcement date.
The California Medical Association (CMA) has surveyed the major plans on their 5010 readiness. With the exception of Medi-Cal, all report they are on target for 5010 implementation on January 1 and that they do not expect any delays or complications.
With the CMS announcement, CMA has learned that some managed care plans will allow for contingencies. For information on which major managed care plans will allow for extended enforcement, CMA has created a quick reference guide, “Managed Care 5010 Quick Reference Guide.”
Several other resources to assist with the transition are available from CMA, the American Medical Association and CMS. These resources are spelled out in our publication, “Preparing for the New HIPAA 5010 Standards: A Guide for Physicians,” available in CMA’s online resource library.
Contact: CMA’s reimbursement helpline, (888) 401-5911 or mkelly@cmanet.org.
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7. United Healthcare rolls out View360° program
In October, United Healthcare began notifying physicians of a new program to identify patients who may need certain recommended screenings, treatment or exams. Called View360°, this program is voluntary and only includes data on United Commercial and Medicare Advantage members. However, participation may impact incentives for physicians associated with the HMO program, both commercial and Medicare.
Along with the notice, United included a summary report based on claims data from December 31, 2008, through June 30, 2011, that identifies patients they believe may be candidates for specific treatments or screenings consistent with Healthcare Effectiveness Data and Information Set criteria. While not sent in conjunction with the physician reports, affected patients do receive notice from United regarding indicated preventive health services.
The summary report outlines when each test or procedure was last performed, and when it is next due. Physicians or their assigned staff may review the summary for discrepancies and can submit corrections or updates via hardcopy or through the View360° online secured web portal (click the View360° link from the Clinician Resources menu). Information submitted to United through both the web portal or via hardcopy is updated monthly.
Download a copy of the notice that was recently mailed to physicians.
Questions about the View360° program should be directed to the United Healthcare View360° program Support Team at (866) 270-5588 or view360mail@uhc.com.
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8. What the demise of the "super committee" means to California physicians
The Joint Congressional Committee on Deficit Reduction (the super committee) declared defeat on November 21, producing no consensus on a package to increase revenues or reduce spending by $1.2 trillion.
The super committee has missed a unique opportunity to reduce the deficit by repealing the flawed Medicare sustainable growth rate (SGR) payment formula once and for all. Addressing the SGR would have reduced government spending and protected access to health care for seniors.
This means there won’t be a complete repeal of the SGR payment formula this year. The 27.4 percent Medicare SGR payment cut still looms on January 1, 2012. Options for SGR relief outside of the super committee process have ranged from short-term patches of a year or two to longer-term relief that would provide for a transition to a new Medicare physician payment system.
The scope of the next SGR intervention will come into better focus when Congress returns from its Thanksgiving break. Legislators have a number of significant items of unfinished business (extending unemployment insurance and the alternative minimum tax and other items) that will require action before departing for the Christmas holidays, which means there will be a legislative vehicle to address the SGR. Organized medicine will be urging Congress to stop the Medicare SGR cuts for as long a period as possible. However, given the rancorous environment, it is unlikely that it will stop the cuts for more than a year or two.
Cuts that take effect in 2013
The super committee’s failure to come to an agreement now triggers across-the-board spending cuts, called sequestration, to begin January 1, 2013. Congress may try to undo the sequestration deal because the military takes 50 percent of the cuts; however, both Republican and Democratic congressional leaders have reiterated their support for the original deal.
If nothing changes, on January 1, 2013, the entire Medicare program will take a 2 percent cut, including physician Medicare payments, Medicare Advantage and graduate medical education. The Medicaid program is completely protected from cuts under the sequestration agreement.
“We have been told time and time again that protecting patient safety and access to care is a priority of this congress and this administration. We cannot rely on those empty promises anymore,” said James T. Hay, M.D., President of the California Medical Association (CMA).
“In fact, the super committee’s failed efforts were announced just weeks after the Obama Administration approved unconscionable 10 percent cuts to California’s Medicaid program, which serves the most vulnerable of our patients. CMA physicians will stand together and continue to urge congressional and state leaders who are responsible for this mess to stop the cuts. Most California physicians will be forced to close their doors if payments are reduced by nearly 30 percent,” Hay noted.
What you can do
Please keep calling, writing and meeting with your members of congress. It is imperative that we stop the 27 percent SGR cuts before January 1, 2012.
Use the American Medical Association Grassroots Hotline at (800) 833-6354; plug in your ZIP code and it will automatically connect you to your representative and senator. CMA will be aggressively pushing Congress to stop the cut.
Thanks to physicians for all of your work on these super committee issues. CMA physicians left no stone unturned. California physicians made more phone calls to congress than any other state.
Medicare participation
Physicians also need to make decisions about their Medicare participation for the coming year. Please see CMA Medical-Legal document # 0151, “Medicare Participation (and Non-Participation) Options,” to understand your options.
Contact: Elizabeth McNeil, (415) 310-2877 or emcneil@cmanet.org.
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9. AMA presents lifetime achievement award to William N. Guertin
The American Medical Association (AMA) presented William N. Guertin with the 2011 Medical Executive Lifetime Achievement Award at its 2011 AMA interim meeting in New Orleans. Guertin currently serves as the executive vice president of the Alameda-Contra Costa Medical Association (ACCMA), and has spent 40 years serving ACCMA’s 3,000 physician members and subsidiaries.
“We are pleased to present Guertin with this award honoring his outstanding commitment to the Alameda-Contra Costa Medical Association for the past 40 years,” said AMA Chair Robert M. Wah, M.D. “He is dedicated to advocating for improvements to our health care system that benefit both physicians and patients.”
Over the course of his career, Guertin represented the interests of physicians as a vigorous advocate on their behalf. He challenged overzealous regulators and health plans, helped organize and promote programs to improve public health, and administered 10 separate ACCMA subsidiaries engaged in various activities of importance to physicians. This included a blood bank, peer review organizations, medical groups, a retirement-investment program, a medical collection agency, a political action committee and the management company for a doctor-owned professional liability insurance company that insures more than 7,000 physicians in four states.
He served on the Board of Directors of the American Association of Medical Society Executives and was its president in 2002, and was twice the Chairman of the Medical Executives Conference in California. He currently represents the California Medical Association (CMA) on the Physicians Foundation Board of Directors.
Guertin has received significant local and state recognition for contributions to his community. He won commendations from both the Alameda County and the Contra Costa Boards of Supervisors for his work to improve health care in 2001. That same year, he was also recognized by the California State Senate and Assembly in a joint resolution commending his efforts to improve health care. He has also served in numerous consultative positions to strategic planning and restructuring committees for the CMA and AMA.
He will retire from the Alameda-Contra Costa Medical Association on December 31, 2011, and will continue in a consultative role on political affairs to the Medical Insurance Exchange of California.
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10. FAQ: Are you being investigated by the Medical Board?
A Medical Board of California (MBC) investigation is an extremely serious matter. Your professional reputation and career are on the line. How you act when you are being investigated could affect the investigation's outcome.
The MBC initiates investigations because of reports it has received through complaints or matters that were reported pursuant to the Business & Professions Code §§801.01 through 805. MBC investigates complaints for two or more acts of simple negligence, or single events involving gross negligence and incompetence, excessive drug prescribing, violation of narcotic laws, self-use of drugs or alcohol, unethical conduct, sexual misconduct, conviction of a crime and other unprofessional behavior.
In order to help physicians understand the MBC investigation process, the California Medical Association (CMA) offers medical-legal document #0705, "Medical Board Investigations." The document discusses the procedural aspects of an MBC investigation, including physician response to the notice of an investigation, investigator access to medical records, the interview and the filing of an accusation. If the case goes forward, the document also includes information on preparing for the administration hearing.
This medical-legal document, as well as the rest of CMA's medical-legal library, is available 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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11. Reminder: Legislative rural caucus to hold two informational briefings on the Medi-Cal experience
The California State Legislative Rural Caucus is holding an informational briefing to learn about the experiences of physicians and their patients in rural areas, particularly in regard to Medi-Cal.
The California Medical Association (CMA) would like to encourage rural physicians and their patients to come out, attend and speak about their experiences with Medi-Cal. In particular, CMA encourages physicians to share how they will be affected by 10 percent reimbursement rate cuts recently announced by the Centers for Medicare & Medicaid Service. As recent data shows, Medi-Cal patients already have a harder time getting access to health care than privately insured patients. These new cuts will have drastic impacts on both providers and patients.
Northern California Briefing
Wednesday, November 30, 2011
10 a.m. to 12 p.m.
CSU Chico Student Union
400 West 1st Street
Chico, CA 95929
The Rural Caucus, chaired by Assemblymember Linda Halderman, M.D., (R-Fresno) is composed of members of the Senate and Assembly from both parties who represent rural California districts. The committee explores issues affecting residents of these areas.
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12. Upcoming webinars
11/30: Provider Enrollment in the Medi-Cal EHR Incentive Program: On December 15, 2011, individual providers (who treat substantial percentages of Medi-Cal patients) will be able to enroll in the Medi-Cal Electronic Health Record (EHR) Incentive Program. In that program, providers can receive up to $63,750 in incentives over six years. During this webinar, representatives from ACS (the Medi-Cal fiscal intermediary) will walk through the process for individual providers to enroll in the incentive program, and answer questions you may have. The one-hour webinar will be November 30 at 12:15 p.m.
12/7: Medicare 2012: Final Rules: Michele Kelly from CMA's Center for Economic Services will cover the final 2012 Physician Fee Schedule changes and of other changes that physicians and their staff should be aware. The one-hour webinar will be December 7 at 12:15 p.m.
12/14: Individualized Treatment Plans for Patients with Diabetes: The CMA Foundation is planning a webinar to support physicians and other health care providers in improved diabetes management, led by Dr. Anne Peters, professor of medicine at the Keck School of Medicine of USC, Director of the USC Westside Center for Diabetes, and Director of the Comprehensive Diabetes Center at Roybal Community Medical Center. The one-hour webinar will take place Wednesday, December 14, 2011, at 12 p.m. To register, click here. For more information, including a presenter bio, click here.
To register for these webinars, visit the CMA event calendar.
Contact: CMA's member help center, (800) 786-4262 or memberservice@cmanet.org.
13. Featured member benefits:
Auto and Homeowners Insurance: CMA members receive 10 percent off auto insurance from Mercury Insurance. For more details, call Mercury Insurance Group at (888) 637-2431 or visit www.mercuryinsurance.com/cma.
Group Dental Program Open Enrollment: It’s open enrollment time for the California Medical Association-sponsored Group Dental program. This plan is designed to help you, your family and your employees minimize the out-of-pocket expenses of regular dental care.
This program helps you maximize your out-of-pocket savings by using network dentists, but also allows you to use any dentist you like and receive lower benefits. Annual benefits include: $2,000 per person for dental care, using network providers; a low calendar year deductible of $50 per person ($100 per calendar year maximum for families); no deductible on oral exams, x-rays and routine cleanings.
During open enrollment only, members may join as an individual or as a group with your employees.
Remember, the open enrollment period is available once per year. To be eligible for coverage, applications must be received during the special open enrollment period that ends on December 31, 2011.
Call a Client Service Representative at (800) 842-3761 for more information, email cmacounty.insurance@marsh.com or download a brochure and application
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