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:
- Health Net Federal Services awarded Tricare contract beginning late 2017
- Blue Shield implements system fix to correctly pay HPV9 claims
- Covered California announces plan offerings for 2017
- Anthem Blue Cross announces changes to reimbursement policies and claims software
- Last chance for some providers to prevent deactivation by Medicare
- UHC to require prior authorization for select outpatient surgical procedures
- CMA publishes MACRA resource center and preparation checklist
- CMS releases proposed 2017 Medicare physician fee schedule
- DOJ files lawsuit to block two health insurance mega-mergers
- New online Medi-Cal provider enrollment portal launch planned for October 2016
- The Coding Corner: The essential facts about CPT® modifier 33
Health Net Federal Services (HNFS) has been awarded the contract for managed care support (MCS) for the Tricare West Region, replacing the current MCS contractor, United Military and Veteran Services. Under the $17.7 billion contract, HNFS will provide direct medical care and administrative support services to Tricare beneficiaries throughout the 19 state western region, which includes California.
According to HNFS, a nine-month transition period is expected, with an anticipated start of health care delivery sometime in mid-2017.
HNFS has been the managed care contractor for the Tricare North Region since 2004, servicing approximately 2.8 million beneficiaries in 22 states and the District of Columbia.
Under the Affordable Care Act, health plans are required to provide “first dollar” coverage for preventive services. This means that the plan cannot apply patient cost sharing, such as copays, coinsurance or deductibles, to these services. However, in September 2015, the California Medical Association (CMA) was alerted by a physician practice that Blue Shield of California was applying patient cost sharing when it processed HPV9 claims with CPT code 90651.
CMA escalated the issue to Blue Shield and has been working with the payor since then to correct the issue. Blue Shield confirmed it implemented a system fix on May 18, 2016. The payor also confirmed it identified over 14,500 claims dating back to January 1, 2015, that were reprocessed to pay correctly. The reprocessing project was completed at the end of June 2016.
Physicians are encouraged to review their records to ensure all affected claims were reprocessed correctly and to contact Blue Shield if they identify any that are still outstanding.
Covered California, the state marketplace for health insurance under the Affordable Care Act, recently announced the qualified health plans that were approved to offer coverage in the exchange market for 2017. All of the plans that offered coverage in 2016 will continue to do so in 2017. Three of the plans will also be expanding into new regions this year.
- Molina is expanding its HMO coverage into Orange County (region 18) through delegated relationships with Monarch and Heritage Network.
- 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 through collaboration with Watsonville Community Hospital and Dominican Hospital for inpatient and ambulatory specialty care. Kaiser plans a phased expansion to include the opening of three medical offices in January 2017 and a specialty hub for enrollees to be added by 2020.
Anthem Blue Cross recently notified physicians of upcoming changes to the insurer’s reimbursement policies and claims editing software, called ClaimsXten. The changes will go into effect on October 1, 2016, with the exception of policies for Multiple Diagnostic Ophthalmology Procedures (CA–0050) and Multiple Diagnostic Cardiovascular Procedures (CA-0051), which become effective on October 17, 2016. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated.
The notice included a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules, as well as copies of Anthem’s reimbursement policies.
The changes include the addition of policy on daily unit maximums for certain drugs and biologic substances (CA-0048), including injections for infliximab (Remicade) and bevacizumab (Avastin). The new policy identifies the maximum number of billable units that the health plan has established as the daily dose maximum. Units reported over and above the dose maximum will not be eligible for reimbursement.
Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
Physicians can also access this information via the Blue Cross ProviderAccess website (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section).
Questions about any of the claims editing rules or payment policies can be directed to the Blue Cross Provider Care Department at (800) 677-6669.
Noridian, Medicare’s administrative contractor for California, will soon begin deactivating billing privileges for physicians who received revalidation notices from Noridian but have not submitted completed applications to the Centers for Medicare and Medicaid Services (CMS). Last month, Noridian reported that only 19 percent of providers had responded to the most recent Medicare Part B revalidation notices.
Since the passage of the Affordable Care Act (ACA), all Medicare providers and suppliers have been required to revalidate their Medicare enrollment information under new enrollment screening criteria in an effort to prevent fraud within the Medicare system. Once a Medicare enrollment application is validated, the clock starts ticking on a five-year revalidation cycle. Now that five years have passed since the ACA's revalidation requirement took effect, CMS has initiated a second cycle of revalidation requests.
Noridian will send revalidation notices two or three months prior to each provider’s revalidation due date.
The first revalidation due date for this second cycle was May 31, 2016. Effective August 14, 2016, Noridian will deactivate the Medicare billing privileges for affected physicians who failed to complete their revalidation applications CMS prior to the May deadline.
The due date for the second revalidation round was June 30, 2016. Noridian will deactivate billing privileges for physicians who missed the June deadline on September 13, 2016.
To prevent deactivation, the California Medical Association recommends that practices look up their revalidation dates through the CMS look-up tool. If it shows that your practice missed the deadline, you should submit and sign your application online through the PECOS system immediately to prevent deactivation
If you are ultimately deactivated for failure to respond to a revalidation notice, you will be required to 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
For more information on the revalidation process, see MLN Matters #SE1605.
If you have questions about the revalidation process, click here or contact Noridian at (855) 609-9960.
As indicated in its July 2015 Network Bulletin, United Healthcare (UHC) will begin requiring prior authorization for certain surgical procedures done in a hospital outpatient setting effective October 1, 2016. The new prior authorization requirement includes procedure codes in cardiovascular, cosmetic and reconstruction, ophthalmology, and ENT (ear, nose and throat) specialties.
Prior authorization will not be required to perform the identified procedures if done in an in-network ambulatory surgery center.
For a complete listing of procedures requiring prior authorization, physicians can access the Prior Authorization for Outpatient Surgical Procedures FAQ on the UHC website.
Practices may submit prior authorization requests to UHC via the www.UnitedHealthcareOnline.com website, by calling (877) 842-3210 or by faxing the request to (866) 756-9733.
For questions or concerns regarding this process, physician practices should contact UHC Network Management at (866) 574-6088.
On April 16, 2015, President Obama signed into law the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), changing the health care financing system in the most significant and far-reaching way since the program's inception in 1965.
To help physicians understand MACRA payment reforms, and what they can do now to start preparing for the transition, the California Medical Association (CMA) has published a MACRA resource center.
There you will find an overview of MACRA, and a comprehensive list of tools, resources and information from CMA, the American Medical Association and the Centers for Medicare and Medicaid Services. The resource center also includes an important checklist titled, “MACRA: What Should I Do Now to Prepare?” to help physicians take steps for MACRA implementation. Also available is CMA’s recent webinar, "MACRA: What Is CMA Doing to Improve It? What Steps Can You Take to Prepare Now?"
View the resource center at www.cmanet.org/macra.
The Centers for Medicare and Medicaid Services (CMS) recently released the proposed 2017 Medicare physician payment rule. According to CMS, the new payment rule will transform how Medicare pays for primary care through a new focus on care management and behavioral health.
The proposed rule also begins to implement the California Geographic Practice Cost Index (GPCI) fix, which will overhaul California’s outdated geographic payment localities. This long-overdue fix updating California’s Medicare physician payment regions will raise payment levels for 14 urban California counties misclassified as rural, while holding the remaining rural counties permanently harmless from cuts. The transition to the new localities starts next year, with higher payments being phased in over a six-year period starting in 2017.
The California Medical Association (CMA) is reviewing the complex California GPCI implementation proposal and will provide additional information once that analysis is complete. CMS also made nationwide updates to the GPCI based on new wage, rent and malpractice expense data.
The proposed physician fee schedule for 2017 focuses on improving Medicare payment for services provided by primary care physicians for patients with multiple chronic conditions, mental and behavioral health issues, and cognitive impairment or mobility-related disabilities.
These changes will improve payment for clinicians who are making investments of time and resources to provide more coordinated and patient-centered care. These proposed coding and payment changes will better reflect the resources involved in furnishing contemporary primary care, care coordination and planning, mental health care and care for cognitive impairment, such as Alzheimer’s disease.
CMS estimates that these changes would result in approximately $900 million in additional funding in 2017 to physicians and practitioners providing patient-centered care, mental health care and diabetes prevention.
The proposal would also expand coverage of the Medicare Diabetes Prevention Program (DPP) model to Medicare patients at risk of developing type 2 diabetes. Expansion of the DPP model will help at-risk seniors and people with disabilities lower their risk factors and prevent their condition from advancing to type 2 diabetes. Earlier this year, CMS concluded that the expanded coverage would result in significant cost savings. The proposal also underscores the important role of prevention in stemming the tide of chronic disease.
CMA is carefully analyzing the multitude of changes to the physician payment system and will be submitting extensive comments.
Contact: Elizabeth McNeil, (800) 786-4262 or firstname.lastname@example.org.
On July 21, the U.S. Department of Justice (DOJ) filed two lawsuits to block health insurance mega-mergers that would compromise patients’ access to care, and negatively impact the quality and affordability of health care across the country.
“If allowed to proceed, these mergers would fundamentally reshape the health insurance industry,” U.S. Attorney General Loretta Lynch said at a press conference. “They would leave much of the multi-trillion dollar health insurance industry in the hands of three mammoth insurance companies, restricting competition in key markets.”
The California Medical Association (CMA) has long-held concerns over reduced competition and increased health plan market power. “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," said CMA President Steven E. Larson, M.D., MPH.
For the past six months, there had been speculation over whether federal antitrust officials would intervene to stop a $54 billion merger between Anthem and Cigna and a $37 billion deal between Aetna and Humana. The companies argued the mergers would benefit consumers and shareholders, but many legislators, state regulators and medical associations, including CMA and the American Medical Association, remained concerned that the deals would reduce competition and drive up costs for patients.
Earlier this year, CMA conducted a survey to determine California physicians’ perspective on the Anthem-Cigna and Aetna-Humana mergers. The results showed that 85 percent of California’s physicians opposed the mergers.
The CMA survey – which gathered data from 989 practices in 47 California counties, representing physicians from a range of specialties and practice sizes – sought not only to gauge California physicians’ temperature on the proposed mergers, but also to gather insight into the tactics undertaken by insurance companies in their negotiations with physicians.
The vast majority of surveyed physicians were concerned that market consolidation would narrow physician networks, making it more difficult for patients to find care from in-network physicians; reduce physicians’ ability to advocate on behalf of their patients; and reduce the quantity or quality of services that physicians can offer their patients. (To see full CMA survey results, click here.)
Physicians strongly believe that health insurer consolidation compromises the ability of physicians to advocate for their patients. Physicians’ experience with past mergers demonstrates that increased market power allows insurers to exert control over clinical decisions, which has undermined the patient-physician relationship and eliminates crucial patient care safeguards. Competition among health insurers, on the other hand, can lower premiums, enhance customer service and spur innovative ways to improve quality while lowering costs.
The California Department of Health Care Services (DHCS) plans to launch its new Medi-Cal provider enrollment system in October. The Provider Application and Validation for Enrollment (PAVE) system will transform provider enrollment from a manual paper-based process to a web-based portal that providers can use to complete and submit their applications and verifications and to report changes.
PAVE will improve the provider enrollment experience by minimizing errors, improving the application process and significantly reducing the time required to process provider enrollments.
DHCS is seeking Medi-Cal fee-for-service providers who are interesting in testing the new enrollment system in advance of the launch in October. Testing will begin in August and will continue for two weeks, but only equates to about eight hours of total time commitment over that two-week period. Providers will test the system at their leisure from the convenience of their home or office. Providers can test using a PC, tablet or smartphone. DHCS will provide training, daily support calls and test scripts. As a testing team provider, you’ll enjoy the following benefits:
- Getting a look at PAVE before other providers
- Opportunity to identify potential bugs or system needs and recommend solutions
- Directly impact improvements to the final PAVE system as a result of your testing
If you are interested in volunteering to be a tester, email PAVE@dhcs.ca.gov.
For more information, visit www.dhcs.ca.gov/provgovpart/Pages/PAVE.aspx.
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 American Medical Association (AMA) introduced CPT® modifier 33 Preventive service in response to the Affordable Care Act (ACA), which requires health care insurers to cover, in full, specified preventive services and immunizations. When appended to a CPT® code describing a preventive service, modifier 33 alerts the insurer that the service is covered and payable under the ACA.
Here are the essential facts to apply modifier 33 with success.
Append 33 for private payors only
Medicare payors do not recognize modifier 33, and will not reimburse claims submitted with the modifier. Medicare requires the use of dedicated G codes to describe covered preventive services (e.g., G0202 Screening mammography, producing direct digital image, bilateral, all views). A guide to Medicare-covered preventive services may be found on the Medicare website.
Services may be covered in-network only
AMA’s CPT Assistant (December 2010) explains that insurers may require cost sharing for those services that are not covered under ACA. Insurers also are permitted to impose cost sharing—or choose not to provide coverage—for recommended preventive services that are provided out-of-network. Lastly, treatments resulting from a preventive screening are subject to cost-sharing if the treatment is not itself a recommended preventive service.
Append 33 to all eligible services
If a provider provides multiple preventive medicine services to the same patient on the same day, append modifier 33 to the codes describing each preventive service rendered.
Don’t use 33 for designated preventive services
Do not append modifier 33 for “separately reported services specifically identified as preventive,” per CPT® Appendix A. For example, 77057 Screening mammography, bilateral (2-view film study of each breast) is a designated screening service. Similarly, do not append modifier 33 to HCPCS G codes describing preventive services provided to Medicare beneficiaries, such as G0103 Prostate cancer screening; prostate specific antigen test (PSA) or G0389 Ultrasound b-scan and/or real time with image documentation; for abdominal aortic aneurysm (AAA) screening.
Office visits aren’t usually separately reimbursed
If a covered preventive service is part of an office visit, the insurer may not impose cost sharing if the primary reason for the visit is to receive preventive services; however, per AMA, cost-sharing is allowed for an office visit if the office visit and covered preventive services are billed separately, and the primary purpose of the office visit is not to deliver the covered preventive services. To illustrate, CPT Assistant (December 2010) provides the following examples:
- A 45-year-old male individual receives a cholesterol screening test, which is a recommended preventive service, during an office visit for hypertension management. The plan or issuer may impose cost-sharing requirements for the office visit because the recommended preventive service is billed as a separate charge and the office visit was not primarily for preventive services.
- An individual receives a recommended preventive service that is not billed as a separate charge. The primary purpose for the office visit is a recurring abdominal pain and not the delivery of a recommended preventive service. Therefore, the plan or issuer may impose cost-sharing requirements for the office visit.
- An individual receives a recommended preventive service that is not billed as a separate charge, i.e., it is part of the office visit and the delivery of said service is the primary purpose of the office visit. Therefore, the plan or issuer may not impose cost-sharing requirements for the office visit.
33 may also apply to screening turned diagnostic
You may also apply modifier 33 when a preventive service must be converted to a therapeutic service. Per CPT Assistant (December 2010), “The most notable example of this is screening colonoscopy [45378 Colonoscopy, flexible, proximal to splenic flexure; diagnostic, with or without collection of specimen(s) by brushing or washing, with or without colon decompression (separate procedure)] that results in a polypectomy [e.g., 45383 Colonoscopy, flexible, proximal to splenic flexure; with ablation of tumor(s), polyp(s), or other lesion(s) not amenable to removal by hot biopsy forceps, bipolar cautery or snare technique].”
Note that the above example applies only to payers who adhere to AMA guidelines. Medicare specifies different guidance if a screening colonoscopy leads to polyp removal, which can be found in MLN Matters Number SE0746, available on the CMS website.
Have your documentation ready
Medical records are not required when reporting a claim with modifier 33, but must be available upon request.
MEDICARE: Noridian recently implemented enhancements to its Medicare portal as a result of recommendations received through a website satisfaction survey. The enhancements were launched July 15, 2016, and included an update to allow administrator access to oversee up to 25 tax identification numbers, improved calendar date entry options and improvements to the appeals submission success rate. For additional information, please see https://med.noridianmedicare.com/web/jeb/topics/nmp.
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.
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.
8/17: Medicare Provider Enrollment: Strategies for Revalidation, Reporting Changes and Avoiding Deactivation: Since the passage of the Affordable Care Act (ACA), all Medicare providers and suppliers have been required to revalidate their Medicare enrollment information under new enrollment screening criteria in an effort to prevent fraud within the Medicare system. Knowing your revalidation due date and having up-to-date enrollment records are necessary to receive the correct compensation for treating Medicare beneficiaries. Deactivation or revocation of Medicare provider enrollment can result in uncompensated services and unnecessary burdens on your practice. This webinar will provide guidance on navigating the Medicare revalidation and enrollment process. Experts from Noridian will review how to avoid top errors and other key issues including finding revalidation due dates, filling out the correct information on enrollment applications, responding to all requests for additional information and keeping enrollment records up to date. This webinar will also review using new tools and tutorials.
Contact: CMA’s member help center, (800) 786-4262 or email@example.com.
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 firstname.lastname@example.org.
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 email@example.com. Questions about membership, including technical website issues, should be directed to CMA's member help center, (800) 786-4CMA or firstname.lastname@example.org.
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 email@example.com.