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:
- No on Prop 46 – get engaged!
- United to make some changes to Premium Designation program, but serious concerns remain
- Change in prior authorization form for prescription medications becomes effective October 1
- Are you losing money from virtual credit card payment fees?
- Ask the expert: How long does TRICARE have to request a refund?
- Noridian denies 300,000 claims for E&M services in error
- System error causing some Anthem Blue Cross claims to be underpaid
- Fall 2015 is new implementation date for ICD-10
- DocbookMD messaging app now a FREE CMA member benefit!
- The Coding Corner: Time as the controlling factor in E&M coding
- CMA advocacy at work
- Payor updates
- Save the date
- Problems getting paid?
- Health plan provider newsletters
By now, many of you are familiar with the Medical Injury Compensation Reform Act (MICRA) lawsuit initiative that will appear on the November 4, 2014, ballot. Proposition 46 is being opposed by a coalition of doctors, community health clinics, Planned Parenthood Affiliates of California, local governments, working men and women, business groups, taxpayer groups, hospitals and educators, all of whom know that the measure will lead to more lawsuits and higher health care costs. What’s more, it will threaten personal privacy and jeopardize people’s access to their trusted doctors or clinics. Practices are encouraged to get engaged now!
What you can do
Sign up formally (as an organization, practice or individual) in opposition to the campaign
Visit the campaign website at www.NoOn46.com to add your name to the growing list of groups and organizations opposing Prop. 46.
Request a CMA staff member to speak to your group, hospital or specialty society
Let your local county medical society or CMA know and we can ensure you’re hearing from the right people about the most recent campaign updates.
Participate in message/media training
The campaign is looking for physicians interested in taking on a more public role speaking to community groups about why this ballot measure should be defeated. Contact Molly Weedn at firstname.lastname@example.org for more information.
Speak to your colleagues, patients and community
Use the resources at NoOn46.com to talk to your colleagues, patients, friends and family. Don’t forget to speak to community members as well – groups such as Rotary, Kiwanis, Soroptimist and more provide great venues for presentations.
Order campaign collateral
Download the Order Form to receive office posters, English- and Spanish-language patient brochures, campaign buttons, message cards and more. You can also order directly online by visiting NoOn46.com.
Spread the message on social media
If you’re active on social media, start by following the California Medical Association and No on Prop 46. Retweet and repost the information that is being put out to help spread the word about how dangerous and costly Prop. 46 will be for everyone. For questions about how to start a Twitter or Facebook account or how to engage with CMA, please contact Brooke Byrd at email@example.com.
United Healthcare (UHC) has agreed, at the urging of the California Medical Association (CMA), to make some changes to its Premium Designation program. However, UHC refused to address many critical problems that CMA had identified, and CMA still believes the program continues to have serious shortcomings. CMA continues to urge UHC to make additional, more meaningful changes with its physician rating and tiering program.
"In its current form, the program will not only confuse patients but will also fail to provide them with meaningful information that could actually assist them in making important health care decisions,” wrote CMA President Richard Thorp, M.D., in an August 13, 2014, letter to the insurer.
The program uses clinical information from health care claims to evaluate physicians against various quality and cost-efficiency benchmarks. CMA believes that the program as currently planned will only lead to confusion among patients and physicians and fails to achieve a central stated goal of UHC –to modify physician practice patterns to improve both quality and cost-effectiveness.
Since the June rollout of the Premium Designation physician assessment reports, doctors have reported numerous problems including (1) the inability to decipher and obtain clarification of the complex assessment reports, (2) insufficient time to thoroughly review and appeal the results of the physician reports, (3) the misattribution of costs related to facilities or other physicians to the assessed physician, and (4) the inability to speak with a UHC representative who could provide feedback on ways to improve performance and meet the program benchmarks for future assessments.
CMA in its letter also reiterated its concerns with the ineffective appeal process for physicians who identify errors in the data or who have a high rate of patient non-compliance. CMA believes the appeal process should afford physicians the ability to discuss their concerns with a UHC medical director of the same or similar specialty and that physicians wishing to dispute their status should have a minimum of 60 days to appeal, rather than the 30 days currently allowed.
"With the many flaws in the Premium Designation Program that have been identified, CMA is concerned that UHC will needlessly harm physicians and inappropriately steer patients away from quality physicians," Dr. Thorp wrote.
Given the significant impact this program could have on a physician practice, CMA also recommended that UHC provide an interactive educational program for physicians and their staff on the background and specifics of the program.
CMA recently received notification that UHC will indeed incorporate changes into its notification letters to proactively inform physicians about the availability to speak to a market medical director upon request. UHC has also committed to providing additional educational resources and educational webinars on the Premium Designation program. While these changes are viewed as a step in the right direction, UHC has regrettably chosen to avoid making any substantive changes to the Premium Designation program. The serious flaws that were ignored by UHC and remain in the program, CMA continues to believe, can cause real damage to physicians and patients, especially as UHC begins to use the inaccurate designations as a basis of steering patients into various tiers.
The first UHC Premium Designation letters and results were mailed in early June to over 25,000 physicians with the results publicly displayed in the insurer's network directory on August 6, 2014. A second round of assessments will be distributed in fall 2014, with publication set for early January 2015.
CMA had previously urged UHC to delay implementation of the program for a minimum of six months to allow time for the insurer to address deficiencies with the program and to allow physicians the opportunity to familiarize themselves with the initiative. United Healthcare responded citing the longstanding history of the Premium Designation program (established in 2005) and previous incorporation in 41 other states across the country as a basis for moving forward with implementation as planned in California.
Physicians who encounter problems with their physician assessment reports or that have concerns regarding their Premium Designation can contact United Healthcare at (866) 270-5588. Practices that are unable to obtain answers to their questions or resolve the issue with United Healthcare directly should contact CMA at the number below.
For more information on the Premium Designation program, visit the United Healthcare website at www.unitedhealthcareonline.com.
Contact: CMA's reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.
Over the next several months, a new law (SB 866) will take effect that streamlines and standardizes the prior authorization process for prescription drugs. The new law requires all insurers, health plans (and their contracting medical groups/IPAs) and providers to use a standardized two-page form for prior authorizations of prescription medications.
Additionally, if a health plan or insurer fails to use or accept the prior authorization form, or fails to make a determination within two business days, the prior authorization request is deemed approved. Currently, plans have five business days in which to make a determination, while practices are often forced to sort through hundreds of different prior authorization forms to locate the one needed.
The new law does not expand the list of medications that require a prior authorization, but for those medications where a prior authorization is required, prescribing physicians must submit (and plans and insurers must accept) the new standardized two-page form. Please note the two-page form only applies to medication prior authorization requests; it does not apply to requests for authorization of procedures.
The Department of Managed Health Care (DMHC) and the Department of Insurance (DOI) jointly developed the standardized authorization form and implementing regulations with stakeholder input. The two agencies, however, will be enforcing the regulations on different timetables.
The regulation for DMHC-regulated products, which includes all HMOs, their contracting medical groups/IPAs, and most Blue Cross and Blue Shield PPOs, becomes effective January 1, 2015. However, the regulation for DOI-regulated products, including all other PPOs and the Blue Cross and Blue Shield Life & Health products, becomes effective on October 1, 2014.
The form (No. 61-211) will be available on the plan and insurer websites as well as the regulators’ websites soon, and can be submitted via paper, electronic transmission, telephone, web portal or another mutually agreeable method.
Anthem recently notified practices that it is streamlining the process by requiring use of the form for all product types on October 1. The California Medical Association (CMA) has asked Blue Shield for details about how it plans to implement and is waiting to hear back.
CMA is in the process of developing a physician resource sheet on the new law and will publish when it’s completed.
If your practice accepts virtual credit card (VCC) payments from payors, you put yourself at risk of losing a significant amount of your contractual reimbursement to high interchange fees.
When paying claims, some payors have shifted from paper checks to electronic payment methods, including payor-issued VCCs. With this method, a payor sends credit card payment information and instructions to physicians, who process the payments using standard credit card technology.
This method is beneficial to payors, but costly for physicians. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are born by the physician practice and can run as high as 5 percent per transaction for physician practices.
The American Medical Association (AMA) is offering a free webinar aimed at educating physician practices on the pitfalls of electronic payments, including VCCs. The webinar, “Stop Paying to Get Paid: Effective Electronic Payments,” will provide attendees with knowledge of electronic payments, an overview of the implications of accepting virtual credit card payments and an introduction on how to implement the new HIPAA standard electronic funds transfer (EFT) transactions in their practices, which can save practices money.
The free webinar takes place on Tuesday, September 16, at 9 a.m. PST, the and also offers one hour of continuing medical education credit.
For more information on electronic payments and avoiding high fees, including a VCC tip sheet, see AMA's EFT toolkit and "The effect of health plan virtual credit card payments on physician practices" (free AMA login required).
Recently, physicians may have started to receive TRICARE requests for refunds related to overpayment from the governmental health carrier. As a result, the California Medical Association’s Center for Economic Services has compiled a list of the most frequently asked questions and answers related to these TRICARE refund requests.
How long does TRICARE have to request a refund?
Pursuant to federal law, TRICARE is authorized to seek refunds of overpayment for dates of service as far back as 10 years, per Title 32: Subtitle A, Chapter: 1, Subchapter M, Part 199.11 - Overpayments recovery. (f) (6) (E) (v)).
How long does a physician practice have to respond to the overpayment request?
Physicians have 30 days to respond to the refund request. Failure to respond will result in the offset of monies against future payments until the full overpayment amount is received.
Can I bill the member for the balance?
Physicians should review the overpayment notice very carefully. In some instances, patients may be held financially responsible for the amounts owed.
Last fall, the Centers for Medicare and Medicaid Services experienced some editing issues with new patient evaluation and management (E&M) codes that resulted in incorrect claim denials. These issues began in October 2013, and were thought to have been corrected in late January 2014. The California Medical Association recently learned, however, that some claims continued to be denied incorrectly through July 15, 2014.
In January, Noridian, California's Medicare contractor, began reprocessing claims that had been denied in error and correcting those subjected to overpayment recovery. Unfortunately, while implementing the corrections, Noridian inadvertently applied the edit to established patient E&M codes 99211-99215, again resulting in incorrect denials
Noridian has corrected the editing for both the new patient codes and the established patient codes, and claims received by Noridian on and after July 16, 2014, should be processed correctly.
Noridian estimates that about 300,000 claims were denied in error, dating back to October 2013, and is now working on reprocessing all affected claims. It expects to complete the reprocessing project around the end of September.
Physicians do not need to resubmit the claims to Noridian. The claims will be automatically adjusted.
For more information, see Noridian's July 22 notice on this issue.
The California Medical Association (CMA) has received physician complaints that Anthem Blue Cross is applying a sequestration cut to their payments, causing some claims to be underpaid. The issue appears to affect claims in which Medicare is the patient’s primary plan and Anthem Blue Cross CalPERS is the supplemental plan. After Medicare processes the claim and forwards on, Anthem’s system appears to be applying a 2 percent sequestration cut to the amount they would normally pay as a supplemental plan in error.
While the individual amounts are small, they can quickly add up for a practice.
CMA escalated the issue to Anthem and has learned that a system issue is causing the underpayments. Anthem is reporting that it does not anticipate a fix until 2015. Until the fix is implemented, Anthem is exploring a work-around to prevent this error
Again, this issue only affects the supplemental payment amount on claims in which Medicare is the primary payor and Anthem Blue Cross CalPERS is the supplemental carrier.
CMA has asked Anthem to identify the claims that have been underpaid to date, automatically reprocess affected claims, and to continue reprocessing affected claims on a monthly basis until the fix is implemented. CMA will report any further details as we hear back from Anthem.
The Centers for Medicare and Medicaid Services (CMS) published a final rule, officially setting Oct. 1, 2015, as the new ICD-10 implementation deadline. The bill including a temporary patch of the sustainable growth rate, passed by Congress in April, also included a delay in ICD-10 implementation, which was previously to begin on Oct. 1, 2014. The new deadline allows providers, payors and others in the health care industry time to ensure their systems and business processes are ready to go on Oct. 1, 2015.
ICD-10 (The International Classification of Disease tenth revision) is a system of coding created in 1992 as the successor to the previous ICD-9 code set. ICD-10 will include new procedures and diagnoses, which the U.S. Department of Health and Human Services hopes will improve the quality of information available for quality improvement and payment purposes.
CMS also announced that it will implement a “comprehensive testing approach,” including end-to-end testing, leading up to the October 2015 implementation date. The testing will be available to physicians in January, April and July next year, giving physicians the chance to help determine the preparedness of their practices and the industry for this transition. More information about end-to-end testing will be available soon.
Physicians can take advantage of the American Medical Association’s free ICD-10 resources, including tip sheets that offer guidance on completing an impact assessment, determining training needs, conducting testing and improving documentation.
For additional information about ICD-10, visit www.cms.gov/ICD10.
The California Medical Association (CMA) is excited to embark on a new partnership with DocbookMD – the secure messaging application for physician-to-physician and physician-to-care team communication. DocbookMD, previously available in some counties, is now offered as a free member benefit to all CMA members.
Across the country, more than 25,000 physicians in 41 states use DocbookMD. DocbookMD is available for iPhone, iPad and Android devices, and now boasts a web version for PC and Mac. CMA members can download the “DocbookMD” app on their mobile device for free from the Apple App Store or Google Play. Once downloaded, open the app and select “Create Account” to complete the registration process. You will be asked a series of security questions to verify your identity and CMA membership. For a step-by-step explanation of the registration process, click here.
For more information on DocbookMD, Docbook Enterprise and additional features of the DocbookMD application, contact DocbookMD Director of Partnerships Chad Shepler at (512) 383-5822 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, managing editor for AAPC, a training and credentialing association for the business side of health care.
CPT® guidelines allow you to consider time as “the key or controlling factor to qualify for a particular level of [evaluation and management (E&M)] services” when counseling and coordination of care dominate (comprise more than half) the physician/patient encounter. Coding based on time may allow you to select a higher-level E&M service than would otherwise be appropriate, based on the elements of history, exam and medical decision-making.
Counseling and coordination of care entail a discussion with a patient and/or the patient’s caregivers concerning one or more of the following:
- Diagnostic results, impression and/or recommended diagnostic studies
- Risk and benefits of management (treatment) options
- Instructions for management (treatment) and/or follow up
- Importance of compliance with chosen management (treatment) options
- Risk factor reduction
- Patient and family education
You should document all pertinent information discussed during the session in the medical record. For example, “30 minutes of counseling” isn’t sufficient. Instead, the provider should summarize the discussion that comprises the counseling or coordination of care. Best practice is to document the beginning and ending time of the counseling and/or coordination of care, and the beginning and ending time for the overall face-to-face visit.
When reporting E&M services by time (rather than the key components of history, exam and medical decision-making), you should use CPT® “reference times” to determine an appropriate E&M service level. The reference time is stated in the final sentence of the CPT® E&M code descriptor (e.g., “Physicians typically spend 30 minutes face-to-face with the patient and/or family”). Reference time for established outpatient codes are:
- 99211 = 5 minutes
- 99212 = 10 minutes
- 99213 = 15 minutes
- 99214 = 25 minutes
- 99215 = 40 minutes
CPT® states, “When codes are ranked in sequential typical times and the actual time is between to typical times, the code with the typical time closest to the actual time is used.” For example, when reporting a time-based, established outpatient E&M lasting 19 minutes, you would report 99213.
Consider the following sample note:
Family discussion on 5/10/2014 with Jane Doe (daughter) and Joe Doe (son) regarding their mother Mary Doe, MRN # 12345, DOB 2/2/45. Mary is a current patient of mine who was recently diagnosed with cancer of the left breast that is very aggressive. I discussed prognosis and treatment options for Mary’s aggressive breast cancer, including surgery, recovery time and chemotherapy and its side effects. I gave them literature from the American Cancer Society, and the name of local support groups that they could contact. I spent a total of 42 minutes with Jane and Joe. Both parties verbalized understanding. I answered all their questions, and they are in agreement with my plan, as outlined above.
In this case, proper code selection is 99215 (with a reference time of 40 minutes).
A final consideration: Not all E&M service codes include reference times. For example, per CPT®, “Time is not a descriptive component for the emergency department levels of E&M services because emergency department services are typically provided on a variable intensity bases….” Likewise, observation codes 99234-99236 do not have a reference time. Because these services do not include reference times, they should not be reported with time as the controlling element.
“Being a member of the CMA means knowing that you always have a helping hand to reach out to and someone who will advocate for us when we are dealing with difficult payor issues.”
David Bryson, M.D.
CMA member since 1992
UNITED: United Healthcare has announced updates to its medical policy, drug policy, coverage determination and utilization review guidelines effective September 1, 2014. Physicians can view all United Healthcare medical policies in their entirety online by visiting the United Healthcare website www.UnitedHealthcareOnline.com > Tools & Resources > Policies & Protocols > Tools & Resources > Policies, Protocols and Guides > Medical & Drug Policies and Coverage Determination Guidelines >Medical Policy Update Bulletin.
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.
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.
9/10: HIPAA Update: Are You Compliant with the Final Omnibus Rule? The Final HIPAA Rule went into effect in 2013. There are so many changes to HIPAA privacy, security, breach and enforcement that this rule is referred to as an "Omnibus Rule." Many changes have a profound impact on medical practice workflow. Changes are also relevant if you use an electronic health record. This webinar provides an overview of the HIPAA changes and key steps medical practices can take to comply with HIPAA. HIPAA enforcement penalties can be severe for medical practices who are not compliant!
9/17: Managing Difficult Employees and Reducing Conflict in the Practice: Very few medical or business schools teach hands-on human resources management skills and techniques. This information-packed workshop will teach you the secrets of how to lead, coach and manage difficult employees; set practice values; and reduce conflict in the practice.
9/25: Informed Consent for Psychotropic Medications: What's Required of Physicians, Hospitals and Nursing Homes: This webinar will review informed consent requirements for psychotropic medications for patients in or being transferred to skilled nursing facilities. The webinar will include a review of current statutory and regulatory law and a discussion of recent efforts to reduce the use of antipsychotic medications in nursing home patients. Informed consent procedures in nursing homes have recently come under scrutiny, with particular focus being placed on physician responsibilities and hospital and nursing home practices.
10/1: Family Medicine, Frontline of Care: Family Medicine specialists are often gatekeepers under many payor models, and face competing pressures from the patients to gain access, the payors to control cost, and potentially third party vendors (e.g. durable medical equipment providers) that may offer to help to provider by providing completed referral forms etc. that are not in the physician’s best interest. This webinar will review strategies to help the provider take a pro-active approach to dealing with these external pressures, as well as review basics in documentation, prescribing, referring, and practice management.
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.