CMA Practice Resources (CPR) is a free email bulletin from CMA's Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability.
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In this issue:
- Aetna to require additional accreditation requirements in order to be paid for certain
surgical pathology services - Update on two Anthem Blue Cross issues pending with the Department of Managed
Health Care - Meet your CMA Center for Economic Services advocate: Mark Lane
- Urgent survey response requested: State releases plan to move all Medicare/Medi-Cal
patients into managed care plans - Aetna erroneously terminates providers from California network
- Document, Document, Document
- United Healthcare announces extension of HIPAA 5010 enforcement
- What’s a COHS?
- Act now to avoid the 2013 e-prescribing penalty
- CMA advocacy at work
- Payor updates
- Save the date
- Problems getting paid?
- Health plan provider newsletters
- Got questions?
- Tell us what you think
Aetna to require additional accreditation requirements in order to be paid for certain surgical pathology services
Aetna recently notified physicians that, effective August 1, 2012, practices performing in-office pathology testing will be required to be both Clinical Laboratory Improvement Amendments (CLIA) certified and accredited with the College of American Pathologists (CAP).
In a letter to physicians, Aetna claims that the change is consistent with the Centers for Medicare & Medicaid Services (CMS) recognition of CAP as an approved accretions organization for non-hospital anatomic pathology testing.
The California Medical Association (CMA) has voiced concerns with the implementation of this policy and has asked Aetna to explain the need for dual certification. Although CMS may recognize CAP as an approved accreditation organization, CMS does not require both a CLIA certification and a specialty society accreditation to perform in-office pathology testing services. Further, CMA expressed concerns with the ability of physicians to obtain the CAP accreditation prior to the deadline imposed by Aetna. According to CAP, the accreditation process takes approximately 90 days. Additionally, the process of obtaining a secondary accreditation can be very costly for practices.
In addition to their contact with Aetna on this issue, CMA is working closely with the American Medical Association and several other state and specialty medical societies. Stay tuned for further details.
Practices with questions about the letter can contact Tammy Gaul, senior network manager at Aetna, at (215) 775-6604.
Contact: CMA’s reimbursement helpline (888) 401-5911 or mlane@cmanet.org.
Update on two Anthem Blue Cross issues pending with the Department of Managed Health Care
DMHC Claims Audit
As previously reported on January 12, the Department of Managed Health Care (DMHC) ordered Anthem Blue Cross to reprocess provider claims, with interest, dating back to 2007.
The order is based on 2008 DMHC audits of the seven largest health plans in California. These audits found violations of claim payments above the threshold allowed under California law at all seven health plans.
As a result, DMHC assessed administrative fines, required the plans to pay providers the money they were owed and mandated that plans demonstrate improvements to their claims processes to prevent future errors.
All plans, except Anthem, reprocessed affected claims and undertook provider remediation efforts.
January’s order gave Blue Cross 30 days to submit to DMHC a corrective action plan identifying the claims that were not correctly paid and pay the providers as prescribed by law.
Since then, CMA has received a number of calls from physician members inquiring about the status of the order. While CMA is in direct contact with the regulator regarding the issue, DMHC reports that the issue is still pending.
For a full copy of the DMHC press release or to view the full order, please visit their website.
Special Investigations Issue
A second pending issue is CMA’s request that DMHC investigate improper refund requests from Anthem Blue Cross’s Special Investigations Unit (SIU).
As reported in June 2011, CMA filed a formal complaint with the DMHC after learning that the SIU was requesting refunds outside of the 365-day period allowed by California law.
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 has alleged that Blue Cross is using an overly broad definition of "misrepresentation" to seek recoupment on claims older than one year.
CMA had been advised that the complaint has been referred to DMHC’s Enforcement Division, however, the issue had yet to be resolved. DMHC reports this issue is still pending.
As a result, Dustin Corcoran, CMA’s chief executive officer, sent a letter to Brent Barnhart, director of the DMHC, reminding him that the lack of action allows Blue Cross to continue illegally recouping millions of dollars from physicians. Corcoran’s letter requested immediate action, including imposition of heavy deterrent fines and restitution to physicians.
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.
CMA will notify our members as soon as we learn of an update from DMHC on either matter.
Contact: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
Meet your CMA Center for Economic Services advocate:
Mark Lane
Fielding calls from physicians experiencing reimbursement difficulties and finding solutions is a task that requires equal parts patience and persistence.
When it comes time to sum up the finer points of this endeavor, perhaps none can do so better than Mark Lane, an associate director with the California Medical Association’s (CMA) Center for Economic Services (CES).
“It’s kind of like finding that needle in the haystack, and then doing what you can to get it fixed,” Lane said. Over the span of his career, Lane’s developed a pretty good sense of where to start looking for these needles.
More than a decade and a half before joining the team at CES, Lane began his career as a claims processor for plans such as Blue Shield and Health Net. Before long, he had moved up to a position in provider relations, allowing him to get a unique vantage point on the relationship between physicians and payors.
“I basically started at the bottom,” he said. “This is kind of the culmination of all of that. Now I’m able to utilize what I know to cut through the red tape and get things done.”
For physicians struggling through the finer points of the reimbursement process, having someone like Lane help guide them along can help defuse what is often a stressful situation.
“Often times, they don’t know where to go,” he said.”It’s always nice to be able to talk to them.”
In Lane’s experience, a typical reimbursement issue can be caused by something as simple as minor coding issue, to a larger misunderstanding of the contract.
Deciphering just where the process went wrong, however, isn’t always easy.
“It can go both ways,” he said, noting that sometime payors are more than willing to provide information, while other times they are not. “There are times when you have to play hardball.”
Having experienced the physician-payor relationship from both ends, Lane is able to understand the needs and positions of the respective sides, making him an ideal candidate to dive into the so-called haystack and begin working toward an answer.
Luckily for the physicians that call on him for help, Lane’s career has afforded him the one tool that can steer through the complex process, day after day.
“Communication,” he said. “It really is the answer to a lot of these issues.”
Contact: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
Urgent survey response requested: State releases plan to move all Medicare/Medi-Cal patients into managed care plans
On June 1, 2011, the state began its transition of seniors and persons with disabilities (SPD) from Medi-Cal fee-for-service program into managed care plans, and will continue over the next several years until complete. Almost immediately, the California Medical Association (CMA) began receiving a wide range of complaints and reports of serious problems involving disruption of patient care.
Over 50 percent of Medi-Cal patients involved in the initial phases of the transition had been automatically assigned to health plans due to failure to respond to notices during the enrollment period. Was this truly the patient’s fault? Or was this the result of poor planning, lack of communication or other language barriers?
Nonetheless, CMA has received numerous reports of patients losing access to physicians who cared for them for many years, and have also received an increasing number of complaints of plans and IPAs/medical groups refusing to contract with physicians who have been long time Medi-Cal providers.
While CMA has continued to work with the Department of Health Care Services (DHCS) to address those issues, the state now is seeking approval from the Centers for Medicare & Medicaid Services (CMS) to shift “dual eligibles” (persons with Medicare and Medi-Cal coverage) into Medicare and Medi-Cal managed care plans in four counties including Los Angeles, Orange, San Diego and San Mateo on January 1, 2013.
If the state plan is approved by CMS, patients will begin receiving enrollment notices on October 1 through November 31 of this year. Furthermore, the state is once again seeking authority to automatically enroll individuals who do not actively enroll or opt-out within the required timeframe.
The state’s plan is currently in a thirty (30) day public comment period. CMA is collecting data on the extent of problems and other issue physicians and their patients have experienced thus far. Examples of delayed and/or denied medical treatment, disruption in continuity of care, and other issues that negatively impacted the financial viability of your practice can be extremely powerful.
Your participation in this survey is crucial. The information you provide will be reflected in CMA’s response to the state’s proposal and will help us better advocate for solutions.
It is critical that we receive your response no later than 5 p.m., May 4, 2012.
Aetna erroneously terminates providers from California network
The California Medical Association (CMA) has learned that Aetna incorrectly issued notices to over 8,000 California patients stating that their provider had been terminated from the Aetna network and would no longer be accessible to provide care.
This action was the result of an error in their provider system. Providers throughout their California network were erroneously terminated with an effective date of March 1, 2012 and auto-generated letters were then mailed to all members assigned to these terminated providers.
Aetna is in the process of issuing retractions to these termination notices to both members and physicians, and has corrected their provider database.
CMA has confirmed that no gap in physician participation will result from the error. Additionally, claims that may have been processed incorrectly as out-of-network will automatically be reprocessed without the need for the physician to resubmit.
Patients with concerns should be directed to contact Aetna Member Services at the phone number indicated on the Aetna Member ID card. Physicians who have concerns regarding the issue can contact Aetna Provider Services at (888) 632-3862 for PPO, and (800) 624-0756 for HMO and Medicare Advantage plans.
Contact: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
Document, Document, Document
One of the most important responsibilities within any physician office is the need to document information in an accurate and thorough manner, and one of the most crucial aspects of this process is the documenting of telephone conversations with payor representatives regarding billing and collection issues.
Adequate written documentation is a key component of success, as it is difficult to dispute or follow up on a telephone conversation without a written record. Also, due to the length of time that can pass, and the number of calls that an office makes in general, practices will most likely not remember the facts of each individual call. Therefore, the documenting of telephone conversations is extremely important.
When documenting telephone conversations, the details should be clear and legible and should include the following:
- Patient name, date of service, date and time of call
- Name, title and phone number of payor contact as well as person in your practice making the call
- Tracking or reference number, if appropriate
- Requests for follow up calls or actions, including date and time
- Any resolution or outcome
- Record the details of all follow-up calls made on the same form
- Outline of main elements of the conversation including commitments and agreements made by you and the payor and then follow-up with an email to that person to confirm your understanding of the next steps. Keep that sent item in your email!
If a payor makes a commitment to resolve an issue by a particular date, set a reminder on your calendar to follow-up. If the agreed upon resolution doesn’t occur, call your contact back and ask why.
Save these notes either electronically or within the patient’s chart to ensure accurate record keeping.
Tip: Consider creating and using a standardized template in your practice management system or hard copy file for documenting payor conversations to help ensure that each staff member is consistent and complete in their documentation of information.
If your practice management system does not allow for a template for documenting conversations, CMA has created a sample template for physician members.
Contact: CMA reimbursement help line, (888) 401-5911 or economicservices@cmanet.org.
United Healthcare announces extension of HIPAA 5010 enforcement
As CMA previously reported, the Centers for Medicare & Medicaid Services (CMS) announced they would again extend the enforcement discretionary period, allowing practices an additional 90 days to become fully compliant with the use of HIPAA 5010 transaction standards.
CMS’s new 5010 implementation deadline is July 1, 2012. In response, United Healthcare has announced they will mirror the CMS extended enforcement period and will not reject 4010 electronic transactions until July 1, 2012.
CMA surveyed the major payors in California to find out which of them are currently requiring HIPAA 5010 transactions. For information on which major managed care plans will allow for extended enforcement, see CMA’s “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.
CMA encourages all physicians to continue working with their vendors, clearing houses and billing services to transition to the 5010 format as soon as possible. Offices that transmit directly must ensure their software is updated.
Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
What’s a COHS?
A County Organized Health System, referred to as COHS, is a local agency created by a county board of supervisors to contract with the Medi-Cal program to provide Medi-Cal managed care services.
The COHS managed care model ensures Medi-Cal recipients access to comprehensive, cost-effective health care. Each COHS plan is sanctioned by the county board of supervisors and governed by an independent commission. As of July 2011, six COHS plans operate in 14 counties with about one million covered lives. The six not-for-profit plans are:
- CalOPTIMA (Orange County)
- Central California Alliance for Health (Merced, Monterey, Santa Cruz Counties)
- Health Plan of San Mateo (San Mateo County)
- Partnership HealthPlan of California (Marin, Mendocino, Napa, Solano, Sonoma, Yolo
- Counties)
- CenCal Health (San Luis Obispo, Santa Barbara Counties)
- Gold Coast Health Plan (Ventura County)
COHS are required to meet Knox-Keene requirements (the state requirements for managed care organizations to obtain HMO licensure, such as proof of financial solvency), but does not require a Knox-Keene license.
COHS who only offer a Medi-Cal managed care product and do not offer any commercial HMO, PPO or other product types requiring licensure from the Department of Managed Care are regulated solely by DHCS.
For more information, see the California Association of Health Insuring Organizations fact sheet or the Medi-Cal website (search “COHS”).
Questions: CMA’s reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org.
Act now to avoid the 2013 e-prescribing penalty
Physicians have until June 30, 2012 to report at least 10 acceptable e-prescribing events to avoid the 2013 penalty of 1.5 percent on the amount allowed for their fee schedule services. CMS has also provided a six-month period until June 30, 2012, for physicians to electronically file for an exemption to the e-prescribing penalty for 2013. See the CMA’s Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions.
CMA advocacy at work
“Recently we had a major re-credentialing issue with several insurance payers. Our CMA representatives from the Center for Economic Services worked diligently at resolving our issues. They followed up consistently with us and our payers until all our claims were able to be processed. We would have had to close our doors if not for their assistance. Thank you CMA!"
Kate McCaffrey, D.O.
Redwood Osteopathy, Inc.
CMA member since 2003
Payor updates
ANTHEM BLUE CROSS: CMA has received periodic complaints regarding Delta Health Systems, leasing the Blue Cross network, use of the Vpay system as a method of reimbursing physicians for services provided to Delta Health enrollees. Vpay is an electronic payment solution used by Delta Health to replace paper checks. The complaint has been that in order to access the payment from Delta Health, physicians are charged a merchant fee, which can be very costly. In the past, physicians have had the opportunity to opt out of the Vpay system and continue to receive paper checks. However, CMA has learned through Anthem Blue Cross, that Delta Health is suspending all Vpay electronic payments until further notice. Physicians should begin to receive the Delta Health payments by paper check effective immediately.
MEDICARE: CMA’s Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions has now been updated with information on how to obtain the incentive payments for 2012 and 2013 and avoid the payment penalties for 2013 and 2014. Check it out on our website.
UNITED: United Healthcare has announced updates to their medical policy, effective May 1, 2012. The updates include, but are not limited to:
- Transcather Heart Valve Procedures - new policy
- In Utero Fetal Surgery - updated policy
- Cochlear Implants - revised policy
- High Ligation and Endomechanical Ablation for Varicose Veins - revised policy
- Sodium Hyaluronate - revised policy
Physicians can view all United medical policies in their entirety online by visiting the United website www.UnitedHealthcareOnline.com > Tools & Resources > Policies & Protocols > Medical Policies.
Save the date
The California Medical Association (CMA) offers our members free programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon. Most events are PMI CEU Credit Approved.
Upcoming CMA webinars
Most webinars are held over the lunch hour, from 12:15 to 1:15 p.m. and are free for CMA members and their staff. See the event calendar for additional details.
5/2: Medicare Audits: How and Why
12:15 - 1:45 p.m.
Learn more about the current medical review audits currently being conducted by Palmetto GBA, California's Medicare accounting contractor, including how they're being conducted and the reasons for this special study. Representatives from Palmetto will provide an in-depth discussion of the findings of the recent Medicare audits, with an extended question and answer session.
5/9: Marketing 101
12:15 - 1:15 p.m.
Learn about Marketing 101 for the medical practice. Attendees will learn how patients are making decisions on health care today, and how you can become part of that decision making process.
5/16: Telephone Etiquette for Medical Personnel
12:15 - 1:15 p.m.
Proper telephone etiquette is one of the hardest things for people working in a medical office to value highly. This webinar will discuss focusing on quality customer service first, as well as being able to adjust to the customer’s needs, which is proper telephone etiquette.
5/17: California Workers' Comp eBill Part 1: Are You Ready?
12:15 - 1:45 p.m.
Part one of three. This webinar will provide you with an overview of what eBill is, how it works, and the benefits and tools to help you evaluate your practice’s eBill readiness.
5/23: Strategic Planning for Solo, Small and Medium Group Practices
12:15 - 1:15 p.m.
Strategic planning and performance coaching are essential processes and tool to ensure your time, resources and focus are leading you down the right track. Learn how strategic planning and performance coaching can get you, your practice or your organization where you want to go.
5/24: California Workers' Comp eBill Part 2: Implementation
12:15 - 1:45 p.m.
Part two of three. This webinar will provide an overview of the eBill compliance requirements and focus on electronic claims and attachment submission requirements including acknowledgement transactions.
5/30: California's Changing Insurance Marketplace
12:15 - 1:15 p.m.
In this presentation, you will learn more about California’s Health Benefits Exchange and what it will mean for physicians. This year, the Exchange Board and legislature will choose the package of benefits that all Exchange plans must cover and largely determine the standards that plans must meet to be offered on the Exchange, which include delivery system reforms. This will have huge implications for California’s insurance market.
5/31: California Workers' Comp eBill Part 3: Understanding Remittance Advice Rules
12:15 - 1:45 p.m.
Part three of three. This session will provide an overview of the eBill electronic remittance advice rules and how to use these rule as a tool to help automate your back office workflow processes.
Upcoming seminars: Palmetto GBA Medicare Spring Tour
May 8: Santa Clara
8:30 a.m. to 4:30 p.m.
Network Meeting Center and Techmart
5201 Great America Parkway
Santa Clara, CA
May 9: San Francisco
8:30 a.m. to 4:30 p.m.
San Francisco Scottish Rite Center
2850 19th Ave
San Francisco, CA
May 10: Oakland
8:30 a.m. to 4:30 p.m.
Oakland Transpacific Center
1000 Broadway Ste. 109
Oakland, CA
For more information or to register for CMA webinars, view the CMA event calendar.
Contact: CMA’s member help center, (800) 786-4262 or memberservice@cmanet.org.
Problems getting paid?
The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their office staff.
Reimbursement Help Line (888/401-5911)
- One-on-one educational and reimbursement assistance to physician members and their staff
Practice Empowerment
- Tools and resources to empower physician practices
- Seminars and toolkits for physicians and their staff
Experienced Staff
- Staffed by practice management experts with a combined experience of over 125 years in medical practice operations
Need help? Contact CMA’s reimbursement experts at (888) 401-5911 or economicservices@cmanet.org.
Health plan provider newsletters
To make sure that you are aware of important news from your contracting health plans, we encourage you to regularly read plans' provider newsletters and bulletins. Follow the links below to access the current issues.
AETNA: www.aetna.com. Click on "Health Care Professionals" in the main menu, then on "News for Providers" in the left sidebar.
CIGNA: www.cigna.com. Click on "Health Professionals" under "Customer Care" in the main menu. Then, scroll down and click on "Newsletters."
ANTHEM BLUE CROSS: www.anthem.com/ca. Click on "Providers" in the main menu, then on "Professional Network Update" under "Spotlight."
BLUE SHIELD: www.blueshieldca.com. Click on "I'm a Provider," then on "Announcements" under "News and Features."
HEALTH NET: www.healthnet.com. Click on "I'm a Provider" and then "California." Enter username and password, and then click "Online News."
MEDI-CAL: www.medi-cal.ca.gov. Click on "Publications" in the main menu, then on "Provider Bulletins."
MEDICARE/PALMETTO GBA: www.palmettogba.com/j1b. Click on "Publications" in the left sidebar, then on "Medicare Advisory."
UNITED HEALTHCARE: www.unitedhealthcareonline.com. Click on "Tools & Resources" in the main menu, then on "Network Bulletin."
CMA RESOURCE: Find up-to-date profiles on each of the major payors in California.
Got questions?
If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or economicservices@cmanet.org. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or memberservice@cmanet.org.
Tell us what you think
Let us know which topics you would like to see addressed in future issues. Contact CMA's Center for Economic Services at (916) 551-2061 or economicservices@cmanet.org.