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Top Story: Blue Cross seeking to settle overpayment refund requests; physicians encouraged to carefully review settlement language before signing
As previously reported, the California Medical Association has received a number of complaints from physicians that the Anthem Blue Cross Special Investigations Unit is requesting refunds outside of the 365-day period allowed by California law.
Also in this issue:
- California Supreme Court limits recoverable medical expenses to amounts actually paid
- FAQ: Is it OK to charge patients for missed appointments?
- Appeals court upholds constitutionality of MICRA's $250,000 cap on noneconomic damages
- Medi-Cal announces start date for EHR incentive program
- ACS takes over as new Medi-Cal contractor on October 3
- Future physicians gather in Sacramento for CMA's 6th annual Medical Student Leadership Conference
- Please join us for the 15th Annual President's Reception and Awards Crystal Gala
- Upcoming webinars:
Featured member benefits:
Auto and Homeowners Insurance: CMA members receive 10 percent off auto insurance from Mercury Insurance.
Long-Term Disability Insurance: Becoming totally disabled could stop your ability to earn an income in a split second. Make sure you have a reliable financial plan in place that includes long term disability income protection.
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1. Blue Cross seeking to settle overpayment refund requests; physicians encouraged to carefully review settlement language before signing
As previously reported, the California Medical Association (CMA) has received a number of complaints from physicians that the Anthem Blue Cross Special Investigations Unit (SIU) is requesting refunds outside of the 365-day period allowed by California law.
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.
In June, CMA filed a formal complaint with the Department of Managed Health Care (DMHC) asking that it investigate these potential violations. DMHC subsequently referred CMA's complaint to its Enforcement Division.
Within the past week, CMA has received calls from physicians who report that they have been contacted by Blue Cross SIU, offering to reduce overpayment amounts due if they agree to sign settlement agreements. CMA believes some of the recoupment requests that the SIU is trying to settle may be the same requests that are the subject of our complaint filed with DMHC.
Physicians who are approached to sign any type of settlement agreement are strongly encouraged to ask for the offer in writing and to have an attorney review the settlement before signing. Often, these types of settlement agreements require that physicians waive and abandon their legal rights over the moneys at issue.
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 helpline, (888) 401-5911 or economicservices@cmanet.org.
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2. California Supreme Court limits recoverable medical expenses to amounts actually paid
The California Supreme Court recently ruled in Howell v. Hamilton Meats that a plaintiff's medical expenses, to be recoverable as damages, must be both "paid or incurred" and reasonable. The California Medical Association (CMA) filed a brief in this case, and the court's ruling was largely in line with CMA's position.
At issue in this case was whether plaintiffs can recover as damages the full rate charged by their doctors and hospitals or whether their recovery must reflect the amount actually paid or incurred on their behalf. In this important decision, the court makes it clear that a plaintiff cannot recover damages based on a bill for which he or she never incurred liability.
In this case, plaintiff Rebecca Howell sought to recover the full amount of her health care provider's bills as damages after she was seriously injured in an automobile accident negligently caused by a driver for defendant Hamilton Meats & Provisions, Inc. At trial, defendant conceded liability and the necessity of the medical treatment the plaintiff had received, contesting only the amounts of the plaintiff's economic and noneconomic damages.
Although the trial court agreed with the defendant and reduced the past medical damages award "to reflect the amount the medical providers accepted as payment in full," that reduction order was later reversed by the Court of Appeal.
CMA in its brief told the California Supreme Court that since neither the plaintiff nor her insurer ever incurred or paid that amount, the plaintiff should not collect that amount as economic damages. "Rather, the plaintiff should be limited in economic damages to the amount the medical provider accepts as payment," CMA wrote in its brief. "The Court of Appeal's approach will unnecessarily burden society with more cost than is necessary to achieve the goals of compensation and deterrence."
The California Supreme Court agreed with CMA and reversed the judgment of the Court of Appeal, ruling that an injured person is not entitled to recover economic damages for past medical expenses based on a provider's undiscounted bill if that sum that was never paid by or on behalf of the injured person. The Supreme Court unequivocally held that no such recovery is allowed, for the simple reason that the injured plaintiff did not suffer any economic loss in that amount.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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3. FAQ: Is it OK to charge patients for missed appointments?
The California Medical Association (CMA) often receives questions from members as to appropriate billing policy when a patient repeatedly "no-shows" or misses a scheduled appointment. What you may not know is that unless a physician has entered into a contract with a payor that prohibits such charges, a physician may charge a patient when he or she misses an appointment or does not cancel in adequate time to allow another patient to fill the appointment slot – if advance notice of such a billing policy is given. Specific billing rules may also apply with regard to certain payors (e.g., Medi-Cal and Medicare).
For more information about your rights when it comes to billing patients for missed appointments, see CMA medical-legal document #0110, "Billing Patients."
This document includes a detailed discussion about noncovered services, discounts for the uninsured, and discounts for prompt payment and stresses the importance of receiving and maintaining accurate patient financial information. It also contains a sample patient financial responsibility form.
Medical-legal document #0110, "Billing Patients," 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.
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4. Appeals court upholds constitutionality of MICRA's $250,000 cap on noneconomic damages
California's 5th Appellate District Court recently upheld the constitutionality of our state's landmark Medical Injury Compensation Reform Act (MICRA), which caps noneconomic damage awards at $250,000. This case, Stinnett v. Tam, is just the latest in many legal challenges to MICRA that have been funded by trial lawyer groups from across the country.
The California Medical Association (CMA) filed a "friend of the court" brief and also participated in oral argument, telling the court that the broader goal of MICRA—to ensure access to care—is just as relevant today as it was in 1975. CMA noted that as recently as 2005 the Legislature declared that there was a "growing crisis" in physician supply, and that California needs to continue to attract and retain physicians rather than drive them away.
CMA was joined in this case, through CMA's Amicus Curiae Committee, by the California Hospital Association, the California Dental Association and the American Medical Association.
The original complaint, filed in 2007, concluded with a jury verdict awarding the plaintiff $148,302 for past economic loss, $1,242,093 for future economic loss and $6,000,000 for noneconomic damages, also called "pain and suffering."
In a post-verdict motion, the defendant moved to reduce the noneconomic damages award pursuant to MICRA's $250,000 cap. The plaintiff opposed the motion, arguing that MICRA is unconstitutional, because the medical professional liability insurance crisis of 1975 no longer exists, thereby eliminating the rational basis that originally justified MICRA. The trial court disagreed and granted the defendant's motion. The appeals court agreed with the lower court's ruling.
Today, MICRA is still working to restrain premium rates in California, while states without liability reform are seeing dramatically higher premiums. Because of MICRA, California has a system that is affordable, pays patients for their full economic and medical losses, and promotes patient safety and improved patient care.
- MICRA allows patients with justifiable medical negligence claims to receive the following forms of compensation:
- Unlimited economic damages for past and future medical costs.
- Unlimited damages for lost wages, lifetime earning potential or any other economic losses.
- Unlimited punitive damages.
- Up to $250,000 for noneconomic damages (pain and suffering).
MICRA's $250,000 cap on noneconomic damages has proven to be an effective way of limiting meritless lawsuits and keeping health care costs lower, but has been targeted by the trial lawyers because it restricts the amount of money they can collect in attorney's fees. MICRA includes a sliding pay scale to control attorney contingency fees, ensuring that more money goes to patients, not lawyers.
Contact: Samantha Pellon, (916) 551-2872 or spellon@cmanet.org.
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5. Medi-Cal announces start date for EHR incentive program
The California Department of Health Care Services will soon begin accepting enrollments for the Medi-Cal EHR Incentive Program. Enrollment will begin on October 3 for hospitals, November 15 for groups and clinics, and December 15 for individual providers.
Under the American Recovery and Reinvestment Act of 2009 (ARRA, or the "Stimulus Act"), physicians are eligible for financial incentives for demonstrating "meaningful use" of an electronic health record (EHR) system. Medi-Cal providers who meet certain patient volume thresholds will qualify for up to $63,750 paid out over six years, beginning as early as 2011 or as late as 2016.
In the first year that a physician is enrolled in the incentive program, he or she can receive up to $21,250 for purchasing, implementing or upgrading an EHR system. Physicians will not have to demonstrate "meaningful use" until their second year in the program.
Accessing these incentives will require a two-part enrollment. Physicians must first register with the Centers for Medicare & Medicaid Services (CMS) at https://ehrincentives.cms.gov. They must then enroll in the Medi-Cal Incentive Program at http://medi-cal.ehr.ca.gov.
Physicians qualify for incentives if:
- Medi-Cal patients make up at least 30 percent of their patient volume.
- They are a pediatrician with at least a 20 percent Medi-Cal patient volume. (However, pediatricians with 20 to 30 percent Medi-Cal patient volume only qualify for two thirds of the total incentive.)
- They practice in a federally qualified health center, rural health center, or Indian health clinic and at least 30 percent of their patient volume is "needy individuals," such as Medi-Cal, Healthy Families, sliding scale, or uncompensated care.
For more information on the Medi-Cal EHR Incentive Program, see http://medi-cal.ehr.ca.gov. Additional information on the Medi-Cal and Medicare EHR incentive programs, and other CMA HIT resources, is available at /hit.
Contact: David Ford, (916) 551-2554 or dford@cmanet.org.
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6. ACS takes over as new Medi-Cal contractor on October 3
The Department of Health Care Services (DHCS) recently awarded a 10-year contract to Affiliated Computer Services (ACS), which will serve as the new fiscal intermediary for Medi-Cal. ACS will manage claims processing for health care providers in the Medi-Cal fee-for-service program, including physicians, pharmacies, hospitals and others. ACS will assume full responsibility for Medi-Cal claims processing and related services on October 3, 2011. Until then, the current intermediary, Hewlett-Packard Enterprise Services (formerly Electronic Data Systems), will continue to process all claims.
DHCS expects the transition to be seamless and that there will be minimal or no impact on the provider community. Medi-Cal providers will not be required to enter into new agreements with DHCS for submission of claims, electronic funds transfer, or point-of-service/Internet usage. Claims submission, processing, and payment will continue without interruption during this transition. Medi-Cal contact information also remains unchanged, including phone numbers, addresses and websites.
All claim forms and submission processes will remain the same. Physicians should continue to submit claims as usual. Once ACS assumes operations, all claims will be transferred to ACS and will be processed just as they are processed today.
Medi-Cal communications to providers will continue to be issued through the existing channels: provider bulletins, website updates, interactive voice response (IVR) messages, etc. In addition, the telephone service center will be augmented with extra resources to ensure providers have immediate access to assistance should the need arise.
If you have any questions regarding this transition, please contact Medi-Cal at (800) 541-5555.
DHCS and ACS will also be hosting town halls in Anaheim and Sacramento, to help answer questions about the transition. The sessions are free and will be repeated three times a day (morning, afternoon and evening sessions) to accommodate as many attendees as possible.
The Anaheim town halls will be Thursday, September 22, at 9 a.m., 1 p.m. and 6 p.m. at Desert Palms Hotel and Suites. The Sacramento town halls will be Monday, September 26, at 9 a.m., 1 p.m. and 6 p.m. at the Arden West Hilton.
To register for any of these events, email medi-caloutreach@acs-inc.com with the provider name, number of people attending, and the date, time and location of the preferred session.
Contact: CMA's reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
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7. Future physicians gather in Sacramento for CMA's 6th annual Medical Student Leadership Conference
Medical student leaders from across the state gathered at the UC Davis Medical Center in Sacramento on September 10 to discuss important issues such as the future of health care reform, patient safety, political advocacy and health care policy. This year marked the conference's sixth year.
Kicking off the day's events, Paul Phinney, M.D., a Sacramento pediatrician and chair of the CMA Board of Trustees, spoke about "Why Leadership Matters." Dr. Phinney encouraged the students to consider becoming active with CMA, saying it has been a fulfilling experience that has allowed him to make a more significant impact as a physician.
Following Dr. Phinney's presentation, an esteemed panel took the stage to discuss "The Future of Health Care Reform." Speakers included Assemblymember Richard Pan, M.D.; Herb Schultz, regional director of the U.S. Department of Health and Human Services, Region IX; Robert Hertzka, M.D., CMA past president; and James Mason, M.D., CEO of Synermed. Students were encouraged to ask questions of the panelists and a lively conversation ensued about how to tackle the complex reforms that lie ahead and how different modes of practice could be advantaged or disadvantaged.
Just before lunch, keynote speaker Mark E. Servis, M.D., associate dean of the UC Davis School of Medicine, Office of Medical Education, addressed the students to discuss "Patient Safety – Effective Communication with Patients: A Focus on Children and Families in California." As many of the students in attendance were first- and second-year medical students, they found this portion of the day to be extremely educational and enlightening.
Following lunch and a series of breakout sessions, CMA lobbyists Dean Grafilo and Juan Thomas addressed the students about the most recent legislative session. The State Legislature had adjourned the night prior, so the updates were relevant and exciting to the students. Grafilo and Thomas explained the purpose and goals of acting as lobbyists for CMA and encouraged students to become involved with the association's Council on Legislation, which makes policy recommendations to the CMA Board of Trustees on major legislation affecting physicians.
Following the conference, students headed to a local school, Tahoe Elementary, where community partners joined forces to sponsor a Healthy Living Fair. Nutrition facts, food items and community information were available at a number of booths. Over a dozen free Tdap (whooping cough) shots were also administered. Assemblymember Pan, Sacramento City Councilman Kevin McCarty and Chair of the Sacramento School Board's Nutrition Task Force Patrick Kennedy were all in attendance.
This year's conference was a huge success! Nearly 70 students from all 10 medical schools across the state were able to attend, in large part due to a generous grant from the Doctors Company Foundation and a focused effort by CMA and our partner county medical societies. CMA is working with its Medical Student Section to explore a north/south rotation for subsequent leadership conferences. Stay tuned for more details.
See photos from the conference and health fair at http://cal.md/cma-flickr.
Contact: Thomas Lawson, (916) 551- 2078 or tlawson@cmanet.org.
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8. Please join us for the 15th Annual President's Reception and Awards Crystal Gala
The California Medical Association (CMA) and the CMA Foundation invite you to attend the 15th annual President's Reception and Awards Crystal Gala, Sunday, October 16, at the
Marriott Hotel in Anaheim. The gala will take place during CMA's annual House of Delegates meeting.
Honored at the dinner will be incoming CMA President James T. Hay, M.D., and the recipients of the CMA Foundation Leadership Awards.
Attendees will be treated to a special show by renowned performance painter David Garibaldi, followed by a private concert from big-band legends Big Bad Voodoo Daddy. Complimentary childcare and shuttle to and from the event will be available.
Tickets are on sale now for $125 per person, or $1,000 for a table of 10. Even if you will not be able to attend, please consider placing an ad in the dinner program. The foundation is a nonprofit charitable organization, and all ads are tax deductible. Proceeds will support the CMA Foundation's work linking physicians and their communities to raise awareness about important public health issues.
Please RSVP no later than September 30. If you anticipate needing childcare for the event, please email cmaf@thecmafoundation.org by September 23 to make arrangements. For more information or to RSVP, visit the CMA Foundation website.
Contact: Shelley Tirsbek, (916) 779-6662 or stirsbeck@thecmafoundation.org.
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9. Upcoming webinars
9/21: Know Your Rights – How to Identify and Stop Unfair Payment Practices: California law prohibits health plans from engaging in various unfair payment practices. This webinar will discuss the important California laws that protect physicians and how to identify and stop unfair payment practices.
The one-hour webinar is September 21, 2011, at 12:15 p.m.
9/27: Insulin Management: The California Medical Association Foundation's Diabetes Quality Improvement Project is hosting a free clinical education webinar for physicians and other health care providers who care for patients with type 2 diabetes.
The one-hour webinar is September 27, 2011, at 12 p.m.
To register for either of these webinars, visit the CMA event calendar.
Contact: CMA's member help center, (800) 786-4262 or memberservice@cmanet.org.
10. 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 http://www.mercuryinsurance.com/cma.
Long-Term Disability Insurance: Becoming totally disabled could stop your ability to earn an income in a split second. The CMA-sponsored Group Long-Term Disability Insurance Plan protects members in their specialty as a physician with a 10-Year Medical Specialty Definition of Disability. Monthly benefits of up to $10,000 are available to members under age 50 ($6,000 for members ages 50-59).
To learn more about this valuable plan today, including: plan features, cost, eligibility, renewability, limitations and exclusions, please call a client service representative at (800) 842-3761 or email cmacounty.insurance@marsh.com.
Underwritten by New York Life Insurance Company, 51 Madison Avenue, New York, NY 10010; Under Group Policy No. G-29322-0 on Policy Form GMR-FACE/29322-0; d/b/a in CA Seabury & Smith Insurance Program Management • CA Ins. Lic. #0633005; ©Seabury & Smith, Inc. 2011 • AR Ins. Lic #245544 • 777 South Figueroa Street, Los Angeles, CA 90017; 800-775-2020 • COA.Insurance@marsh.com • www.MarshAffinity.com • 51462 (9/11)