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:
- CMA publishes guide on new provider directory accuracy law
- Noridian reports low response rate for Medicare part B revalidations
- Updated payor profiles now available
- United Healthcare extends clinical data submission deadline to Sept. 2
- DMHC IMR/complaint webinar now available on-demand
- CMA publishes new resources on California's mandatory school vaccination requirement
- CMA medical legal library updated for 2016
- California Insurance commissioner urges DOJ to block Anthem/Cigna merger
- Have you submitted your CURES application yet?
- Medi-Cal to reimburse providers for advanced care planning
- Early bird deadline for NEPO Building Healthy Communities Summit is July 15
- The Coding Corner: How coding guidelines define new vs. established patients
- CMA advocacy at work
- Payor update
- Save the date
- Problems getting paid?
- Health plan provider newsletters
On July 1, 2016, a new law took effect that requires plans to ensure that their physician directories are accurate and up-to-date. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payors' networks. The California Medical Association (CMA) has published a new guide to help physicians understand the new law, and what they need to do to avoid penalties.
The guide, "What Physicians Need to Know to Avoid Penalties Under the New Provider Directory Accuracy Law," is free to members in CMA's online resource library.
Noridian, Medicare’s administrative contractor for California, reports that only 19 percent of physicians have responded to the most recent Medicare Part B revalidation notices. Noridian is in the process of deactivating Medicare billing privileges for physicians who received a revalidation notice from Noridian but did not turn in a completed application to the Centers for Medicare and Medicaid Services (CMS) prior to the most recent deadline of May 31.
If you are deactivated for failure to respond to a revalidation notice, you must submit a reactivation application. The date of receipt of the reactivation application will be the new effective date for your Medicare billing privileges. Noridian will not apply a retroactive effective date and no payments will be made for the period of deactivation.
If a revalidation application is received but incomplete, Noridian will contact you for the missing information. If the missing information is not received within 30 days of the request, Noridian will deactivate your billing privileges.
If your revalidation application is approved, no further action is needed.
If you do not know when you are up for revalidation, you can look up your revalidation date through the CMS look-up tool. Those due for revalidation in the near future will display a revalidation due date. All other providers/suppliers will see "TBD" in the due date field.
For more information on the revalidation process, see MLN Matters #SE1605.
If you have questions about the revalidation process, click here or contact Noridian by calling (855) 609-9960.
The California Medical Association’s (CMA) Center for Economic Services has published updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, and other key contacts.
Don’t waste your time searching the internet for this information – members can download CMA’s Payor Profiles free of charge in the CMA Resource Library.
At the request of the California Medical Association (CMA), United Healthcare (UHC) has delayed the expansion of its Clinical Data Submission Protocol in California. Originally scheduled to take effect July 1, the expansion will now be pushed back until September 2.
First introduced in 2015, the program originally targeted only Medicare benefit plans and required physicians to submit all laboratory test results for UHC Medicare patients. The expansion of the program will require practices to submit laboratory tests for all UHC Medicaid and commercial benefit plans.
For more information about the protocol and requirements for submitting data to UHC, physicians should refer to the updated Clinical Data Submission Protocol Frequently Asked Questions and Methods of Clinical Data Exchange.
While UHC lauds the sharing of clinical patient data as an opportunity to support quality and cost-effective patient care, CMA has expressed concerns about the administrative burden, impact on physician practices and proper notice to physicians.
UHC has stated, however,that it will help practices establish the transmission method that works best with their current capabilities. For more information or to speak to the UHC clinical data team, contact the UHC Provider Call Center at (877) 842-3210 or your local Network Account Manager or Provider Advocate.
The California Department of Managed Health Care (DMHC), the regulatory agency that oversees 122 health plans, recently conducted a webinar for the California Medical Association (CMA) to provide an overview of the department with a focus on the DMHC Help Center and its Independent Medical Review (IMR) process.
DMHC Deputy Director of Health Policy and Stakeholder Relations Mary Watanabe provided an overview of the department’s IMR and complaint processes, including the importance of these processes in the policy, legislative and regulatory arenas. Also provided was information on how to submit the IMR/complaint form to the DMHC Help Center, tips and best practices for assisting patients with access to care, billing issues including denials of care, and overview of the provider complaint unit.
This webinar is now available on-demand in CMA's online resource library and is free to all interested parties.
Beginning July 1, 2016, all California schoolchildren are required to have the appropriate vaccinations prior to enrolling in a public or private elementary school or child care center, unless the child has a medical exemption. The new law (SB 277) removes the personal belief exemption from the vaccine requirement. The new rules do not, however, apply to children participating in home-based private schools or independent study programs not requiring classroom-based instruction.
The California Medical Association (CMA) has created new resources and updated existing resources to aid physicians and the public in complying with the new requirement. These resources, available free to members in CMA’s health law library, include information on when children must be vaccinated, which vaccinations are required, and what information physicians must provide to parents or guardians regarding the risks, benefits and adverse reactions to a specific vaccine. The resources also discuss the disclosure of immunization information and reporting of adverse reactions to public health departments.
The available CMA On-Call documents include:
- #3211, “Vaccine Administration”
- #3114, “Vaccine Administration: Mandated Information”
- #3603, “Vaccines, Drugs and Devises: Reporting Adverse Events”
- #4252, “Disclosure of Immunization Information”
On-Call documents are free to members in CMA’s online health law library at www.cmanet.org/cma-on-call. Nonmembers can purchase documents for $2 per page.
Contact: CMA’s legal information line, (800) 786-4262 or firstname.lastname@example.org.
CMA On-Call, the California Medical Association (CMA) online health law library, is fully updated for 2016. One of CMA's most valuable member benefits, On-Call contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. The searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs.
New documents for 2016 include:
- Provider Directories (#7163)
- Self-Referral Prohibitions: Federal Exceptions Related to Other Compensation Arrangements (#1164)
- Self-Referral Prohibitions: Federal Exceptions Related to Managed Care Arrangements (#1163)
- Self-Referral Prohibitions: Federal Exceptions Related to Both Ownership and Investment Interests (#1162)
- Self-Referral Prohibitions: Federal Exceptions Related to Rural or Underserved Areas (#1161)
- Self-Referral Prohibitions: Federal Exceptions Related to Electronic Information (#1160)
- Self-Referral Prohibitions: Federal Physician and In-Office Ancillary Services, Academic Medical Centers and Group Practice Exceptions (#1159)
- Vaccine Administration (#3211)
- The California End of Life Option Act (#3459)
In addition, physicians can find answers to common physician practice questions in some of most frequently referenced On-Call documents:
- Controlled Substances Prescribing (#3201)
- Retention of Medical Records (#4005)
- Medical Records: Allowable Copying Charges (#4002)
- Termination of the Physician-Patient Relationship (#3503)
- Allied Health Professional Relationships: Liability Issues (#3001)
CMA members can access On-Call documents in CMA's online resource center for free at www.cmanet.org/cma-on-call. Nonmembers can purchase On-Call documents for $2 per page.
CPLH, the complete health law library, is also available for purchase in an multi-volume print set or annual online subscription service. To order a copy, visit the CMA resource library or call (800) 882-1262.
California Insurance Commissioner Dave Jones urged the U.S. Department of Justice (DOJ) to block the merger deal between insurance giants Anthem and Cigna. After an extensive review of the Anthem and Cigna merger, Commissioner Jones issued detailed findings that the merger of the second and fourth largest national health insurers is anti-competitive and will harm California consumers, businesses and the California health insurance market.
Jones found that if the merger moves forward, Anthem's market share will exceed 50 percent in 28 California counties, and 40 percent in 38 counties, which would negatively impact California consumers with likely reductions in access, quality of care and affordability of health insurance.
"When it comes to the Anthem and Cigna merger, bigger is not better for California's consumers or the health insurance market," Jones said.
Jones held a public hearing on March 29, where the California Medical Association (CMA), members of the public, Anthem and Cigna executives, consumer advocates, medical professionals, and merger experts provided testimony regarding the merger’s potential impacts.
Just before the public hearing, CMA conducted a survey of California physicians to see how they would be impacted by the proposed merger. An overwhelming 85 percent of physicians oppose the Anthem-Cigna merger, according to the CMA survey. Of 989 physicians surveyed from practices in California, the majority expressed that the health insurer union could narrow physician networks (82 percent), force physicians to provide fewer services (90 percent) and pressure physicians into refraining from aggressive patient advocacy (75 percent).
Additionally, a growing body of peer-reviewed literature demonstrates that greater consolidation among health insurance companies leads to increased health insurance costs.
“Surrendering market power to one corporation does not bode well for California’s patients,” said CMA President Steven E. Larson, M.D., MPH. “Without competition, the health insurance companies will run unchecked. For the sake of those who desperately need medical care, we must not let this happen.”
CMA has long been concerned with the consolidation of health plans and health insurers, and the reduction of competition. When market power is consolidated among just a few companies, insurers contract with fewer physicians, limiting choice for patients, increasing wait times for referrals, and sometimes forcing them to pay more to see out-of-network doctors. Physicians across the country worry that the hardball tactics undertaken by these insurance companies demonstrate that they put profits before patients.
The CMA survey was conducted in collaboration with the American Medical Association and spanned across 47 California counties. Respondents represented a variety of specialties and practice sizes. To see the full CMA survey, click here.
To read the insurance commissioner's letter to the DOJ, click here.
Under California law, all individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate (DEA Certificate) should have registered to use the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016.
The California Medical Association (CMA) has compiled a list of educational materials to familiarize physicians with the registration process and key features of the newly upgraded system, CURES 2.0. These resources are available at www.cmanet.org/cures.
Among the resources is an on-demand recording of CMA's webinar, cohosted with the California Department of Justice (DOJ), to help physicians navigate the CURES 2.0 registration process. The webinar provides an overview of key user features of the updated system and tips on how to avoid technical issues. This webinar is available in CMA's online resource library and is free to all interested parties.
Physicians who experience problems with the new system should contact the DOJ CURES Help Desk at (916) 227-3843 or email@example.com. Providers are also encouraged to report these technical issues to CMA's member service center at (800) 786-4262 or firstname.lastname@example.org.
In another significant step toward normalizing and supporting advance care planning conversations, Medi-Cal is following Medicare’s lead by allowing providers to bill for advanced care planning discussions with beneficiaries.
The Centers for Medicare and Medicaid Services (CMS) began reimbursing codes 99497 and 99498 on January 1, 2016, but it was left up to state Medicaid programs (like California's Medi-Cal) to separately determine whether they would follow suit.
The California Medical Association (CMA) is a member of the Coalition for Compassionate Care Coalition of California, which wrote a letter to the California Department of Health Care Services in March urging the state to “follow the federal government’s lead and take the next logical step – reimburse Medi-Cal providers for advance care planning discussions.”
Specific guidance on use of the advance care planning codes with Medi-Cal beneficiaries has not yet been provided.
These are time-based codes: 99497 is for the first 30 minutes, and 99498 is an add-on code for each additional 30 minutes. Current Medi-Cal reimbursement rates for these codes are:
- 99497: $69.59
- 99498: $62.64
CMA will share additional details as they become available.
The Network of Ethnic Organization (NEPO) 2016 Building Healthy Communities Summit will be held September 16-18 at the Marriott Hotel and Spa in Newport Beach. The Summit is designed to inspire physicians and health care providers to participate in community health efforts and challenge them to improve health care and quality of life in their communities.
Attendees will also have the opportunity to hear from nationally acclaimed thought leaders and network with colleagues. Featured speakers include:
- Dave Jones, California Insurance Commissioner
- George Halvorson, Chair of the First 5 Commission
- Karen Smith, M.D., MPH, Director of the California Department of Public Health
- Rishi Manchanda, M.D., Founder of HealthBegins and author of The Upstream Doctors
Once again, the summit will also include a medical student poster presentation session. NEPO invites any medical student to participate in a poster presentation displaying his or her health care research. This is a wonderful opportunity for students to display their work and network with other health care providers. For additional information, including guidelines and application, click here.
Please join us in building on and expanding the important work of NEPO at the largest multi-ethnic physician convening in the country.
Register by July 15 and save $100 off the summit cost. Click here for more information or to register.
Contact: Kyla Aquino Irving, (916) 779-6643 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.
The distinction between “new” and “established” patients is vital for correct evaluation and management (E/M) code assignment, coding compliance and reimbursement.
CPT® defines an established patient as one who “has received a professional service from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years.”
The first requirement of the definition is that a patient has received a “professional service.” Within the context of E/M code selection, CPT® defines a professional service as “those face-to-face services rendered by physicians and other qualified health care professionals who may report evaluation and management services reported by a specific CPT code(s).”
The “face-to-face” nature of a professional service is important: Medicare policy [Centers for Medicare & Medicaid Services (CMS) Transmittal R731CP, Change Request 4032] notes, “An interpretation of a diagnostic test, reading an x-ray or EKG etc., in the absence of an E/M service or other face-to-face service with the patient does not affect the designation of a new patient.” A patient is new, for instance, if the physician interpreted test results two years earlier, but had provided no face-to-face service to the patient within the previous three years.
The second requirement of the definition addresses patient status relative to other providers in a group practice. When a patient becomes established with a physician who works in group practice, the patient is established with all physicians of the same specialty/subspecialty in the group. The American Medical Association allows an exception for new physicians seeing for the first time a patient established to the practice. CPT Assistant, November 2008, features the following Q&A:
Question: Can new physicians who come on board to a group practice with their own tax identification numbers charge a new evaluation and management code for patients they see?
Answer: According to CPT guidelines, a new patient is one who has received no professional services from the physician or another physician of the same specialty who belongs to the same group practice within the past three years. Also, if a physician is new to this group practice and had never seen or billed a patient previously though his tax ID number, this should be considered a new patient for the purposes of this physician billing for his evaluation and management service.
Not all payors agree with this logic; inquire with your individual payors before billing as new any patient who is established with another physician of the same specialty/subspecialty within a group.
Two providers in the same practice may both classify a patient as new, if they see the patient for different reasons and if the providers are of different specialties recognized by (CMS). For a list of Medicare-recognized physician specialties, visit the CMS website. CPT® guidelines specify, “When advanced practice nurses and physician assistants are working with physicians they are considered as working in the exact same specialty and exact same subspecialties as the physician.”
For example, a general surgeon in a large multiple-specialty practice sees a patient in 2014 to remove some skin lesions. In early 2016, the same patient sees an internist—who is a member of the same multispecialty practice as the surgeon who previously treated the patient previously—for a new condition. Because the surgeon and internist (who are of different specialties) saw the patient for unrelated problems, the internist may report the initial visit using new patient codes (e.g., 99201-99205).
If a provider is covering for another provider, a patient’s status is relative to the provider who is unavailable (not the covering provider). For example, Dr. Smith is covering for Dr. Jones, who is on a family vacation. Patients who are established with Dr. Jones would be treated as established with Dr. Smith, even if Dr. Smith has not seen the patient previously.
Finally, note that location doesn’t affect a patient’s “new” or “established” status. CPT Assistant (June 1999) explains:
Consider Dr. A, who leaves his group practice in Frankfort, Illinois, and joins a new group practice in Rockford, Illinois. When he provides professional services to patients in the Rockford practice, will he report these patients as new or established?
If Dr. A, or another physician of the same specialty in the Rockford practice, has not provided any professional services to that patient within the past three years, then Dr. A would consider the patient a new patient. However, if Dr. A, or another physician of the same specialty in the Rockford practice, has provided any professional service to that patient within the past three years, the patient would then be considered an established patient to Dr. A.
In other words, where the patient is seen doesn’t matter. If the provider treats a patient with face-to-face service within the previous three years (in any location), that patient is established (in all locations).
“CMA, thank you so much for your quick and helpful response. It’s wonderful to have your assistance readily available to address the never-ending amount of changes in regulations and requirements impacting physicians.”
Seth Anderson, M.D.
Santa Barbara County Medical Association
CMA member since 1978
UNITED HEALTHCARE: Effective for dates of service beginning January 1, 2017, United Healthcare will require commercial and Medicare Advantage drug-related claims to be submitted indicating the National Drug Code (NDC) number, quantity and unit of measure. According to the UHC frequently asked questions, the NDC should be in field 24D of the CMS-1500 claim form. Claims submitted without an NDC number will be denied, while providers will be required to resubmit the claim with the appropriate NDC indicated in order to obtain reimbursement. For additional information, including frequently asked questions on how to submit claims containing an NDC to United Healthcare, please visit the UnitedHealthcareOnline.com website.
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
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.
7/13: MACRA: What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now? This webinar will provide a brief overview of the new Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) payment changes, with an emphasis on the California Medical Association’s (CMA) advocacy with the Centers for Medicare and Medicaid Services (CMS) to significantly improve the MACRA regulations for physicians. This webinar will also discuss what steps to take now to be ready.
7/27: Save Lives California (Prop. 56): Message Training: Nearly 17,000 California kids get hooked on smoking every year, and about half of them will eventually die from tobacco-related illnesses. Helping to reverse this trend is the California Healthcare, Research and Prevention Tobacco Tax Act of 2016 (also known as the Save Lives California campaign and Prop. 56), a ballot initiative that will ask voters this November to raise the state’s tobacco tax by $2 per pack. This webinar will present an overview of the tobacco tax measure and educate participants on the campaign’s key messages so that the voices of physicians are unified in the months leading up to the election.
8/10: Organized Medicine 101: How to Be an Effective Advocate for Your Future Profession and Your Future Patients: From expanding access to care for low-income families, protecting communities from infectious disease, or saving lives through tobacco control, CMA is at the forefront of state and national policy discussions. However, we can only build on this success with the continued engagement of all of our passionate and articulate members, particularly the engagement of our medical student and resident members. This webinar will provide important information and direction about ways to get involved in the important advocacy work of CMA and organized medicine. First-year medical students, newly matched residents and other members who have not been active in CMA campaigns are strongly encouraged to attend.
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.