CMA Practice Resources (CPR) is a free monthly e-bulletin from the California Medical Association’s practice management experts that focuses on critical payor and health care industry changes and how they directly impact the business of a physician practice. Each issue includes tips on reimbursement and contracting related issues along with information on the latest practice management news.
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In this issue:
- Be prepared for Covered California changes in 2017
- Time to verify your patients’ eligibility and benefits for 2017
- United Healthcare to introduce Navigate, new narrow network product, in 2017
- United Healthcare delays 2016-2017 Premium Designation physician results
- Anthem Blue Cross continuing medical record reviews and patient health assessments
- Reminder: Changes to your Medicare participation status for 2017 are due by December 31
- The Coding Corner: The big changes in CPT 2017
In 2016, Covered California, California's health benefit exchange, enrolled approximately 1.4 million individuals in qualified health plans. It is critical that physician practices understand their participation status, which products are being offered and what changes to expect in 2017.
Some of the most significant changes for Covered California in 2017 are:
- All Covered California enrollees, including those with a PPO or EPO, will be assigned to a primary care physician. The assignment will either happen by January 1, 2017, or within 60 days of the enrollee’s effective date with the plan.
- United Healthcare will exit California’s exchange marketplace at the end of 2016, impacting approximately 1,200 enrollees. All other plans that offered coverage in 2016 will continue to do so in 2017.
- Three plans will be expanding into new regions this year:
- Molina is expanding its HMO coverage into Orange County (region 18).
- Oscar is expanding its EPO coverage into San Francisco (region 4); Santa Clara (region 7); and San Benito, Santa Cruz, and Monterey (region 8).
- Kaiser is expanding into Santa Cruz and Monterey (region 8).
- Anthem Blue Cross, which offered a PPO product in all geographic regions in 2016, will return to offering only its EPO product for individual/exchange enrollees in the following counties:
- Region 1: Northern counties
- Region 2: North Bay Area
- Region 3: Greater Sacramento
- Region 4: San Francisco County
- Region 5: Contra Costa County
- Region 6: Alameda County
- Region 7: Santa Clara County
- Region 8: San Mateo County
- Region 9: Santa Cruz, San Benito, Monterey
- Regions 15 and 16: Los Angeles counties
- Region 17: Inland Empire
- Region 18: Orange County
- Region 19: San Diego County
Physicians are reminded that the Anthem Blue Cross EPO product does not offer member coverage for services provided by an out-of-network provider except in urgent/emergent situations. The change in product type from PPO to EPO may also result in changes to the provider network network and access to participating hospitals in each region. Click here to see which hospitals will NOT be participating in the Pathway PPO/EPO plans effective January 1, 2017. Physicians in affected counties who are currently contracted with Anthem for the exchange/mirror PPO product are encouraged to check the directory to confirm whether they will be part of the plan’s EPO network in 2017.
- Anthem Blue Cross will now only offer its PPO product in the five following regions for 2017.
- Region 10: Central Valley
- Region 11: Fresno, Kings, Madera counties
- Region 12: Central Coast
- Region 13: Eastern counties
- Region 14: Kern County
There are some other minor benefit design changes for 2017, such as some increases and decreases to copays for different plan tiers and visit types. For more information, see the 2016 and 2017 standard benefit design grids.
To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2017.”
The tip sheet is available free to members at www.cmanet.org/exchange.
The beginning of a new year brings with it changes to your patients’ eligibility and benefits. Physicians are urged to be diligent in verifying each patient’s eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year also means that both calendar year deductibles and visit frequency limitations reset. And, with open enrollment, patients may even be covered by a new payor.
Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.
And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and that, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice, as your ability to collect can decrease significantly after the patient leaves the office.
Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money.
United Healthcare (UHC) recently notified physicians that it will be introducing a new commercial narrow network PPO product, Navigate, to the California marketplace effective January 1, 2017. Due to an operational error, the notice issued to California providers inadvertently referenced United Healthcare of Nebraska, which is also launching the Navigate product. UHC has since issued a corrected notice.
UHC says the Navigate plan is its most recent effort at providing a reduced-cost health care option to employers. This network offers access to a significantly narrowed network of PPO physicians, while requiring patients to coordinate and obtain prior referral for specialty care from their selected primary care physician.
The Navigate network of providers will mirror United’s existing Core provider network, with the exclusion of providers and hospitals from the Sutter Health network. The terms of each physician’s UHC base contract, including compensation, will apply to the new Navigate plan. According to United Healthcare, factors influencing a physician’s participation in the Navigate plan network mirror those of the Core product, including cost, quality and efficiency criteria. For an overview of the Navigate plan, click here.
In addition to the narrowed Navigate provider network, UHC will be utilizing the W500 wrap network, which will include the remaining PPO providers not selected to participate in the Navigate provider network. Similar to Core, Navigate patients can only access physicians in the W500 network for emergency services and related admissions, urgent care services and other prior approved services.
In August 2016, UHC sent notices, including a unilateral contract amendment, to physicians who were automatically opted into the W500 product. The terms of the underlying UHC PPO contract will apply to those physicians being opted into the W500 product for Navigate.
As always, physicians are encouraged to carefully review all proposed amendments to payor contracts. Remember, you do not have to accept substandard contracts that are not beneficial to your practice.
Physicians who are unsure whether or not they are affected by this change, those who have general questions about the amendment or those who wish to dispute their performance rating for participation in the Navigate plan network can contact UHC Network Management at (866) 574-6088.
United Healthcare (UHC) has indicated that distribution of its 2016-2017 Premium Designation assessments will be delayed to December 30, 2016, with the results released to the public on March 1, 2017. UHC had previously announced that the next iteration of its Premium Designation assessment results would be sent to physicians in early November 2016, with the results to be released publicly via the payor's online physician directory on January 4, 2017.
Physicians who encounter problems with their physician assessment reports or who have concerns regarding their Premium Designations can contact UHC at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with United Healthcare directly are encouraged to contact the California Medical Association at (800) 786-4262.
In the Anthem Blue Cross December Professional Network Update, the insurer published a reminder about how it is working with Inovalon, a secure clinical documentation service, to meet the patient reporting requirements specified under provisions of the Affordable Care Act (ACA).
Physicians continue to report receiving requests for medical records from Anthem related to “risk adjustment.” These record requests are a result of the commercial risk adjustment program created by ACA Section 1343. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the needs of a diverse population. Because the information reported by physicians and other providers is at the heart of payment adjustments, health plans must engage providers by requesting copies of medical records that accurately reflect diagnoses and/or underlying health conditions to comply with risk adjustment program requirements [77 Fed. Reg. 17220, 17241 (March 23, 2012)].
Anthem has contracted with Inovalon to conduct medical chart reviews, utilizing one of several methods of collecting medical record information from physician practices, including:
- Scanned or faxed medical records that providers’ offices send to Inovalon
- Onsite medical record reviews by clinical personnel
- Automated medical record retrieval from providers’ electronic health record system (upon authorization from the practice)
Anthem has also announced that it will continue to offer financial incentives to physicians for completing member health assessments for patients with certain exchange/mirror products. The health assessments are voluntary and are separate from anything related to the commercial risk adjustment requests.
Anthem will continue to work with Inovalon throughout the year to request that physicians complete the health assessments. The assessments will be completed using Inovalon’s secure, electronic tool (ePASS) or using the Encounter Subjective, Objective, Assessment and Plan (SOAP) Note provided by Inovalon for each identified patient.
For patient assessments completed for dates of service on or after June 1, 2015, physicians are now eligible to receive $100 for each properly submitted electronic SOAP note submitted through ePASS, in addition to their normal office visit fee. Physicians electing to submit their patient assessment data to Inovolan via secured fax, instead of electronically, are eligible to receive $50 in addition to the office visit fee.
The information is being requested as part of a Covered California requirement that participating health plans collect and maintain information about the health status of their plan enrollees to better manage their health conditions.
According to Anthem, there are no penalties for non-compliance with the health assessment at this time.
Physicians who have questions regarding the health assessment program can reference the Anthem FAQ or can contact Anthem Provider Services at (855) 854-1438. For specific health assessment questions, contact Inovalon at (877) 448-8125.
Physicians are reminded that the deadline to make changes to their 2017 Medicare participation status is December 31, 2016. This year, physicians are receiving postcards as part of the annual Medicare Participation Program, highlighting awareness of the short timeframe where a physician can change their participating or non-participating status. Physicians who are happy with their current status do not have to do anything.
As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely. Details on each of the three participations options are as follows:
- A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients.
- A non-participating provider can make assignment decisions on a case-by-case basis and bill patients for more than the Medicare allowance for unassigned claims. Non-participating physician fees are 95 percent of participating physician fees. If you choose not to accept assignment, you can charge the patient 9.25 percent more than the amounts allowed in the participating physician fee schedule (which equates to 15 percent of the non-participating fees).
- Physicians who opt out of Medicare are bound only by their private contracts with their patients. Medicare's limiting charges do not apply to these contracts, but Medicare does specify that these contracts contain certain terms. When a physician enters into a private contract with a Medicare beneficiary, both the physician and patient agree not to bill Medicare for services provided under the contract.
Physicians who want to change their participation status for 2017 must send a letter to Noridian, California’s Medicare contractor, postmarked by December 31, 2016.
The California Medical Association (CMA) also has information on physicians' Medicare participation options in CMA On-Call document #7209, "Medicare Participation (and Nonparticipation) Options." On-Call documents are free to members in CMA's online resource library at www.cmanet.org/cma-on-call. Nonmembers can purchase On-Call documents for $2 per page.
Physicians can also visit CMA’s MACRA resource center at www.cmanet.org/macra to better understand the Medicare payment reforms and access resources to help with the transition. The center is a one-stop-shop with tools, checklists and information from CMA, the Centers for Medicare and Medicaid Services, the American Medical Association and national specialty society clinical data registries.
Contact: Cheryl Bradley, (213) 226-0338 or email@example.com.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
CPT® 2017 will be implemented January 1, and brings with it a number of significant changes in coding. The most significant changes will include revised conscious sedation billing guidelines, expanded telemedicine services and a new category of codes to describe procedures related to dialysis.
Conscious sedation now separately billable
CPT® no longer defines conscious sedation (as an inherent part of any procedure. A total of 441 (mostly endoscopic) codes no longer include moderate sedation. Conscious sedation, when performed and properly documented, now may be reported separately. New conscious sedation codes 99151-99157 are reported according to patient age and the timed duration of the service.
Note: The Centers for Medicare and Medicaid Services (CMS) determined that the moderate sedation work for certain esophageal dilation, biliary endoscopy and endoscopic retrograde cholangiopancreatography procedures differs from that of other endoscopy procedures. In response, CMS augments the new moderate sedation CPT® codes with a gastrointestinal (GI) endoscopy-specific moderate sedation code, G0500, to be applied instead of CPT® 99151-99152 when reporting moderate sedation to Medicare patients in addition to GI endoscopy services specified within the 2017 Physician Fee Schedule Final Rule.
Expanded telemedicine services
For 2017, CPT® introduces modifier 95, which may be appended to designated Evaluation and Management (E/M) service, Medicine and Category III codes (identified in the CPT® manual with a star) to describe telemedicine services. CPT® instructs: “The totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction.” Interactive telecommunications equipment must include audio and video, and the patient and provider must be able to communicate and interact in real time.
New medicine codes for health assessments
E/M code 99420 is deleted and replaced by two new medicine codes to describe health risk assessments, either for a patient (96160) or a patient caregiver (96161), for the benefit of the patient.
Spinal instrumentation updates
Code 22851 is deleted and replaced by three, more precise add-on codes to describe biomechanical devices placed in the intervertebral disc space (with and without arthrodesis, 22853 and 22859, respectively), or attached to vertebral bodies (22854).
Also new, 22867-22870 describe interlaminar/interspinous process stabilization/distraction devices, marketed under several brand names (e.g., X STOP®, NuVasive®), to treat the symptoms of spinal stenosis (pain, cramping and muscle weakness, etc.), with or without open decompression or fusion. The device is implanted between the vertebral spinous processes and is opened or expanded to distract (open) the neural foramen and decompress the nerves.
Laryngoplasty code 31582 is deleted and replaced by four new codes (31551-31554), each describing laryngoplasty for laryngeal stenosis (congenital or acquired narrowing of the airway) by various methods.
Code 31591 Laryngoplasty, medialization, unilateral describes a procedure to alleviate vocal cord weakness or paralysis. The surgeon creates a window in the thyroid cartilage and places a small implant to move the affected vocal fold and hold it in place, so that the functioning vocal fold can close for normal voice and swallowing.
Additionally, 31592 Cricotracheal resection describes excision of a portion of the airway just below the larynx (most commonly to treat stenosis). The larynx and trachea are sewn back together.
More options for varicose vein treatment
New codes 36473 and add-on 36474 involve a combination of mechanical and chemical methods to ablate varicose veins. An intraluminal device is used to disrupt bloodflow and “scratch” the interior surface of a vein, into which medication is then infused.
New dialysis circuit codes
The dialysis circuit is created to allow easy, repeated access to blood vessels to perform hemodialysis. CPT® 2017 introduces nine new codes under the added subhead “Dialysis Circuit,” along with several pages of definitions and instructions.
Code 36901 reports imaging of the dialysis circuit. Code 36902 describes the same service, with the addition of transluminal balloon angioplasty of the peripheral dialysis segment; 36903 describes all the services in 36902, plus transcatheter placement of intravascular stent(s) in the peripheral dialysis segment with all necessary imaging and radiological supervision and interpretation (S&I). Other codes in this group describe transluminal mechanical thrombectomy and/or infusion to treat any/all thrombus without (36904) and with balloon angioplasty (36905) and transcatheter intravascular stent placement (36906). Add-on codes describe angioplasty of the central dialysis segment (36907), stenting in the central dialysis segment (36908), and permanent vascular embolization or occlusion in the dialysis circuit (36909).
Angioplasty adds radiological S&I
CPT® 2017 deletes eight codes to report transluminal balloon angioplasty and replaces them with four new codes (37246-37249) that simplify reporting. The new codes includes all necessary imaging and radiological S&I.
Spinal injections now specify with/without imaging
Codes 62311-62318 are deleted and replaced by 62320-62327 to better differentiate epidural or subarachnoid injections performed with and without imaging guidance, by spinal region.
Fluoroscopic guidance for needle placement (77002) becomes a specified add-on code for 2017, as does fluoroscopic guidance and localization of needle or catheter tip for spine or paraspinous diagnostic or therapeutic injection procedures (77003). CPT® parenthetical instructions provide a full listing of primary codes with which you may report 77002 and 77003.
Mammography codes are overhauled to simplify reporting. Five codes become three (77065, 77066 and 77067), all of which include computer-aided detection to aid in detecting breast cancer, when performed.
Path and lab
New codes to report presumptive drug class screening (80305-80307) are selected based on the method used to perform the test(s). Each of the new codes may be reported once, per test, regardless of the number of drug classes tested.
New codes 81413 and 81414 report genomic sequence analysis of at least 10 or two genes (respectively). The tests identify cardiac conditions such as Brugada syndrome, long QT syndrome, short QT syndrome and catecholaminergic polymorphic ventricular tachycardia.
Code 81422 now reports genomic sequence analysis for fetal chromosomal microdeletions, and a unique code (87483) is added to identify central nervous system infections.
Medicine sees many refinements, few new codes
Nine influenza vaccine codes are revised and are now reported by dosage, not patient age. For example, 90686 eliminates the requirement “when administered to individuals 3 years and older” and adds “0.5 mL dosage.” Code 90674 is added to improve reporting of quadrivalent (e.g., Flucelvax®) vs. trivalent (90661) vaccine.
CPT® adds introductory text to the Psychotherapy section, designating 90832-90838 as “psychotherapy for the individual patient, although times are face-to-face services with patient and may include informant(s). Patient must be present for all or majority of the service.” The phrase “and/or family member” is removed from the code descriptors. Look to 90846 or 90847 when “utilizing family psychotherapy techniques such as focusing on family dynamics.” Do not report 90846 or 90847 for services of less than 26 minutes.
Three new codes are added to describe repair of a paravalvular leak. A paravalvular leak occurs at the annulus of a replacement valve. Code 93590 describes placement of an initial occlusion device (plug) to block a leak at the mitral valve, using a catheter; 93591 describes placement of an initial occlusion device (plug) to block a leak at the aortic valve, using a catheter; and 93592 describes placement of each additional plug beyond the initial occlusion device to block a leak at the aortic or mitral valve, using a catheter.
New code 96377 reports application of on-body injectors (e.g., OnPro®), including cannula insertion. The system automatically provides timed injections (for example, for oncology patients requiring chemotherapy injections).
New, time-based physical therapy, occupational therapy and athletic training evaluation codes (97161-97172) are similar to E/M codes found in the 99000 series, but are specific to therapy.
AETNA: Effective March 1, 2017, Aetna will eliminate second-level appeals for its commercial plans, allowing providers only one level of appeal going forward. Additionally, Aetna will now require the usage of its Practitioner and Provider Complaint and Appeal Request form when physicians submit appeal requests. These changes affect both participating and non-participating providers. For more information, Aetna has created an FAQ with an overview of the appeals process.
MEDI-CAL: With the rollout of the new Provider Application and Validation for Enrollment (PAVE) portal from the California Department of Health Care Services Provider Enrollment Division (PED), providers can now electronically complete and submit applications, report changes to existing enrollments and respond to PED-initiated requests for continued enrollment or revalidation via PAVE.
PED has several resources available to physicians on the PAVE webpage including two interactive sessions each week:
|Drop-in labs||1700 K Street, Sacramento||Tuesdays from 12 to 2 p.m.||There is no structured content for these sessions. Bring your PAVE system questions and PED staff will assist you. A User Profile must be created and any relevant documents uploaded to PAVE prior to attending a drop-in lab. No registration is needed.|
|Q&A webinars||Webinar (register here)||Thursdays at 12 p.m.||This is a question-and-answer format only. There is no structured content for these sessions. PED staff will remain on the line until all questions are answered.|
UNITED HEALTHCARE: United Healthcare has announced updates to its medical policy, drug policy, coverage determination and utilization review guidelines effective January 1, 2017. Physicians can view all United Healthcare medical policies in their entirety online by visiting the United Healthcare website at www.UnitedHealthcareOnline.com > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines >Medical Policy Update Bulletin.
The California Medical Association offers our members free programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon.
Upcoming CMA webinars: January 2017
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 and to register.
1/11: Preventing Burnout: Individual and Organizational Intervention: Physician burnout not only affects physicians, but can potentially have a negative impact on other staff, the organization or practice, and patients under their care on a daily basis. By recognizing and responding to burnout, physicians and their institutions will be able to reduce sources of stress and intervene with tips and tools that support professional wellbeing. This webinar will cover different evidence-based individual and organizational strategies available to implement into daily practice..
1/25: Medicare Changes: 2017 and Beyond: This webinar will focus on changes to the Medicare program in the upcoming year, including the Medicare Access and CHIP Reauthorization Act (MACRA), the 2017 Medicare physician fee schedule, annual updates and other changes. We will review existing programs, such as the Physician Quality Reporting System (PQRS) and the Value Based Modifier system, that may negatively impact payments through 2018, as well as provide tips on how to navigate and prepare for MACRA implementation, which begins in 2017. We will also provide you with education resources that will help you understand what the final rule for 2017 means for your practice.
Contact: CMA’s member help center, (800) 786-4262 or firstname.lastname@example.org.
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
- Tools and resources to empower physician practices
- Seminars and toolkits for physicians and their 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 email@example.com.
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/NORIDIAN: https://med.noridianmedicare.com/web/jeb/fees-news. Noridian publishes individual articles through the Latest Updates section in the left sidebar. The articles are condensed approximately every six-to-eight weeks into a Bulletin.
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.
If you have questions related to any of the articles in this issue, please contact CMA's reimbursement help line, (888) 401-5911 or firstname.lastname@example.org. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or email@example.com.
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 firstname.lastname@example.org.