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:
- $10 million reasons to be a CMA member
- United Healthcare amendment introduces narrow network product
- CMA survey finds workers’ comp reform has brought new challenges for physicians
- Ensure your practice information is up-to-date with contracted payors
- ICD-10 transition guide now available; new resource webpage available
- United Healthcare to pursue EFT and ERA for all contracted physicians in 2015
- Participate in the MGMA Compensation and Production Survey; receive free access to survey results
- Practice check-up: proactive patient communication
- 100,000 Covered California enrollees transitioned into Medi-Cal managed care in January
- CMA webinar program on temporary hiatus; let us know what kind of webinars you want to see!
- The Coding Corner: Clinical documentation improvement
The California Medical Association’s (CMA) Center for Economic Services (CES) has now recouped $10 million from payors on behalf of CMA member physicians. These monies, recovered over the last five years, represent actual physician reimbursements that would have likely gone unpaid without the intervention of the CES team.
Founded in 1999, CES provides CMA members with one-on-one assistance for billing, contracting and payment problems that may arise. With more than 125 years of combined medical practice operations experience, CES staff helps members with issues ranging from underpayment or denials by payors to assisting with contract analysis during negotiations.
Assistance from CES can range from education on how to increase a practice’s efficiency to direct intervention with payors or regulators. This support is reserved exclusively for CMA members.
CES also provides physicians and their staff with access to CMA Practice Resources, a monthly bulletin offering tips for improving practice efficiency and viability. To sign up for a free subscription, visit the CMA website at www.cmanet.org/newsletters.
For practice management tools, newsletters and other online assistance, visit www.cmanet.org/ces.
Setting the stage for its potential future entrance into California’s Exchange, Covered California, United Healthcare (UHC) has begun the process of building its provider networks by amending physician contracts.
United Healthcare has advised CMA that its new Core plan, which will be marketed to employer groups seeking lower premiums and used for its potential future exchange product, will access a significantly narrowed network of approximately 45 percent of UHC’s current PPO provider network.
UHC plans to send amendment notices to physicians selected to participate in the Core network sometime in March. UHC also reports that the terms of each physician’s United Healthcare base contract will apply to the new Core plan.
In addition to the narrowed Core provider network, United will be utilizing a wrap network, named W500, that will include the remaining 55 percent of its PPO provider network not selected to participate in the Core provider network. However, patients can only access physicians in the W500 network for emergency services and related admissions, urgent care services and other prior approved services. For an overview of the Core plan, click here.
UHC sent notices to the 26,000 physicians it is automatically opting into the W500 product on January 20, 2015, with an effective date of April 20. The terms of the underlying UHC PPO contract will apply to physicians who are being opted into the W500 product.
UHC stated that physicians were selected to participate in the Core plan network based on their performance in several cost containment areas including referrals to out-of-network physicians, average episodic cost of care and overall contractual fee-schedule reimbursement during calendar years 2012-2013. Although the cost criteria for the Core program mirrors that of the United Premium Designation program, UHC stated that the two evaluations are unrelated, and that physicians achieving Premium Designation status may not necessarily be included in the narrow Core product network.
The amendment for the W500 product does not allow physicians the option to opt out of just the new product; rather, physicians would have to terminate their underlying United Healthcare PPO agreement in order to opt out of the new Core plan network. Physicians will have 45 days from the date of receipt of the amendment notice to notify UHC if they wish to terminate their participation prior to the April 20 effective date.
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 Core plan network can contact United Healthcare Network Management at (866) 574-6088.
California’s workers’ compensation system is arguably undergoing its biggest period of transformation since its enactment in 1914. Senate Bill 863, signed into law on September 19, 2012, initiated changes to the utilization review process, implementation of an independent medical review and independent bill review process, and a migration to a resource-based relative value scale payment system, among other changes.
In late 2014, after hearing complaints from physicians that these changes have resulted in patient care roadblocks, the California Medical Association (CMA) initiated a survey to solicit physician feedback on their experiences with the SB 863 reforms. More than 200 practices representing physicians in over 35 different specialties responded to the survey.
Sixty-seven percent of physicians reported that they were unable to gain authorization for needed patient care. Of those who reported difficulties with authorizations, 54 percent of physicians cited inappropriate denials of medically necessary tests, procedures or services as the greatest problem.
CMA’s survey also found that 68 percent of physicians do not believe the independent medical review process has been successful in ensuring medically necessary patient care is approved.
Additionally, 60 percent of physicians reported that the new Independent Bill Review (IBR) process has not been successful. Physicians overwhelmingly (90 percent of respondents) cited the downcoding of claims, resulting in underpayment, as the most significant problem. Respondents also reported that the submission cost of $250 to utilize the IBR process is cost prohibitive. Physicians also report that oftentimes when they do file an IBR request, the contractor responsible for issuing a written determination is not compliant with the 60-day response timeframe.
These survey results indicate significant challenges with workers’ compensation reforms and raise concerns as to whether the new processes actually incentivize the denial of necessary patient care and downcoding of physician claims. CMA is working with stakeholders to determine potential next steps to address the issues raised in the survey results.
Click here to view the survey results.
Every practice understands the importance of collecting up-to-date demographic information from patients, including changes to a patient’s address, phone number, insurance, and eligibility and benefits. Ensuring that these items are up-to-date guarantees that the practice can quickly communicate with the patient about test results or other medical issues, as well as schedule and confirm appointments. Accurate patient insurance, eligibility and benefits information also helps to prevent unnecessary denials delays in payment, and goes a long way toward ultimately saving time and money for the practice.
It is equally important that physicians ensure their practice demographic information is up-to-date with any contracted payors.
Reason #1 – Up-to-date practice information such as specialty, address, tax identification number (TIN), practice name, and complete list of physicians in the practice (along with their national provider identification (NPI) numbers) ensures that payments and other vital contractual notices are received by the practice.
Reason #2 – Providing updated, accurate practice information to payors ensures that your information is displayed correctly to patients looking for a physician through payors’ provider directories. It also helps reduce the potential for delayed or denied payments for the practice.
Reason #3 – It will likely keep your practice compliant with your contracts. Most payors have language in their contracts that requires physicians to notify the payor in writing of any changes in their practice.
To ensure that all of your information is accurate, practices are encouraged to review their information with each contracted payor on an annual basis, at minimum. However, if a practice is moving, adding or losing providers, changing the practice name and/or TIN, closing a practice or changing specialties, it’s important to inform the payor ahead of time. Information that should be reviewed includes, but is not limited to:
- Practice name
- Practice TIN
- Practice and physician NPIs
- Practice physical address
- Practice phone number
- Pay-to address
- Physician or lead administrator email address (if available)
- Practice fax number
- Whether the practice is open/closed to new patients
- Languages spoken (if published)
- Products with which the practice is contracted
- Providers included in the contract
- Providers leaving/joining practice
- Hospital privileges
The California Medical Association (CMA) has queried the major payors on their process for updating provider demographic information and compiled their responses into a new resource for physicians, “Updating Provider Demographic Information with Payors,” which is available free for CMA members at www.cmanet.org/ces.
Practices should be advised that updates to provider demographics may take up to 90 days to complete – so submitting an update to the payor as soon as information changes is extremely important.
With eight months until the transition to ICD-10, will your practice be ready be October 1, 2015?
To help physicians prepare for the transition, the California Medical Association (CMA) has published a new resource, “ICD-10 Transition Guide – What physicians need to know,” which includes an ICD-10 transition preparation checklist.
CMA has also created an ICD-10 transition webpage, www.cmanet.org/icd10, that includes important news articles and other ICD-10 transition information. CMA will also be hosting a number of live training events to assist physicians with the transition, with details announced soon.
United Healthcare (UHC) plans to move all contracted providers from paper checks and remittances to electronic funds transfer (EFT) and electronic remittance advices (ERA) in 2015 through Optum’s Electronic Payments and Statement (EPS) system. United Healthcare stated that moving to an electronic process for checks and explanation of benefits will reduce administrative costs.
UHC advised the California Medical Association that they plan to send notice of the change to contracted providers sometime in April. Physicians will be required to select to receive payment either by Automated Clearinghouse (ACH) direct deposit to their bank account or payment through the issuance of a virtual credit card (VCC) payment.
ACH EFT is a funds transfer tool in which payment from payors are processed over the ACH network. Effective January 1, 2014, all health plans and HIPAA-covered entities must use ACH EFT to pay physicians if the physician requests it. ACH EFT transactions typically only carry one fee of about $0.34, while VCC payments are subject to transaction and interchange fees that can run as high as 5 percent per transaction – paid for by physician practices.
The VCC payment method is beneficial to health plans, but costly for physicians. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, the high costs associated with VCC payments are born by the physician practice. For more information on steps a practice can take to avoid high VCC fees, click here.
Practices that do not make a selection of either ACH EFT or VCC will automatically be enrolled to receive payments via the VCC option, costing the practice a significant amount of its contractual payments to high interchange fees.
Practices who are interested in continuing with paper payments in lieu of electronic transfers or that have questions regarding the EPS system can contact a United Healthcare EPS representative at (866) 842-3278. Decisions about allowing physicians to opt out of the EFT option will be made on an individual basis.
For more information on electronic payments and avoiding high fees, including a VCC tip sheet, see the American Medical Association’s (AMA) EFT toolkit, "The effect of health plan virtual credit card payments on physician practices" (free AMA login required).
CMA members now have the opportunity to obtain credible benchmarks for physician compensation and production targets, as well as benchmarks to illustrate the relationship between provider production and compensation, just by taking the Medical Group Management Association (MGMA) Compensation and Production Survey.
The MGMA Compensation and Production Survey collects data on provider and staff compensation, provider revenues, patient encounters and other metrics for a one-year period. Practices of all sizes are eligible to participate.
All survey participants will receive free, online access to the survey results for the areas in which they submit feedback. For instance, if a physician/medical practice completes the physician component, but not the staff component, they will only receive access to physician results and vice versa.
The results will provide compensation and production benchmarks at the national and state levels, as well as for custom regions designated by the state. The benchmarking report includes medical data across multiple indicators including specialty, geographic region, practice setting, years in specialty and method of compensation.
The survey is open through March 13, 2015. You do not have to be a member of MGMA to participate in the survey; however, free registration on the site is required in order to protect your confidential data. Practices are encouraged to download the Preparation Checklist to get a list of data that will be required to complete the survey questions.
Practices with questions about the survey can contact MGMA at 877-ASK-MGMA (275-6462), ext. 1895, or firstname.lastname@example.org.
As practices begin to schedule patients for their annual check-ups, remember that conducting an internal practice check-up is equally important. This is the first in a series of articles aimed at highlighting key areas practices should examine in an effort to improve practice performance.
This month we focus on how clear, proactive patient communication can have a positive impact on both patient and practice satisfaction.
Many practices take the important step of confirming patient appointments ahead of time. However, if you’re not also taking the time to inform your patients about any outstanding balances, copays, deductibles or coinsurance that will be due at the time of their appointment, you’re missing out on a big opportunity.
Proactively communicating with your patients about any balances due at the time of service helps to set expectations and prevent disputes at the receptionist desk. Additionally, failure to collect amounts due at the time of service can be very costly for a practice, as the ability to collect can decrease significantly after patients leave the office.
If you use an automated appointment confirmation system, identify those patients who have balances due and consider pulling them from the automated system and, instead, call them personally. Contacting the patient personally can help in several ways:
- The practice is able to clarify any changes to eligibility or insurance coverage prior to the patient’s visit, which decreases time required for patient check-in by the front office staff.
- Patients are able to discuss financial or coverage concerns individually with a practice representative rather that at the front desk or in front of other patients, which helps to keep the office running smoothly and calmly.
- Patients who receive individualized communication are more likely to refer other patients to the practice.
Remember, every interaction with your patients is a reflection on the practice – a positive patient experience goes a long way. Taking these proactive steps to educate your patients prior to their visit, respond to their questions and alleviate any potential points of contention at the time of service can increase patient satisfaction levels, reduce the stress level of practice staff and ultimately save the practice money. Happy patients…happy practice!
The California Department of Health Care Services (DHCS) announced that approximately 100,000 Covered California enrollees were transitioned from exchange plans into Medi-Cal managed care plans effective January 1, 2015. According to the DHCS bulletin, the affected individuals no longer qualify for Covered California products due to changes in their income and/or family size.
Enrollees whose Covered California plan also offers a Medi-Cal managed care plan in their area will transition to the matching Medi-Cal Managed care plan with no lapse in coverage. Those who had a Covered California plan that did not offer a Medi-Cal managed care plan in their area were automatically enrolled in a managed care plan in their county. Typically, when patients are transitioned to a different plan, there is an effort to maintain continuity of care by matching patients to plans that include their primary care physician. However, CMA has learned that this information was not available at the time of the transition, thus many of these patients were randomly assigned to a managed care plan.
Patients who wish to switch Medi-Cal managed care plans can do so at any time by calling Health Care Options at (800)-430-4263. Coverage will be effective in the following month.
In an All Plan Letter dated December 29, 2014, DHCS outlined continuity of care requirements of Medi-Cal managed care plans (page 5) for patients who are required to switch plans. Specifically, plans are required to contact affected patients within 15 days of enrollment to help the patient initiate the continuity of care process. Additionally, Medi-Cal managed care plans are required to honor prior authorizations for up to 60 days or until a new assessment is completed by the plan. For more information on continuity of care, see CMA On Call document #7051, “Contract Termination by Physicians and Continuity of Care Provisions,” available free to members in CMA's online resource library at www.cmanet.org/cma-on-call.
Notices of the change were sent to patients by Covered California at the end of December, with new ID cards mailed the first week of January.
This change reinforces the importance of verifying eligibility each time the patient is seen to confirm coverage, whether the physician is in-network with the plan and that the correct payor is billed. Physicians can access the Medi-Cal automated eligibility verification system using the patient's social security number if a patient does not yet have an ID card at the time of service.
The new year always brings about exciting opportunities for change and improvement—two elements that are vital to the success and sustainability of any venture. With this in mind and building on the foundation of our existing webinar program, we will soon be introducing new speakers, fresh content and a streamlined schedule. In order to accomplish this we will be placing the webinar program on a temporary hold while we work behind the scenes to bring you a great line up for 2015.
In the meantime, CMA members can access our archived webinars and view them for free by going to www.cmanet.org/webinars.
Also, are there topics already being covered that you would like to learn more about? Is there a subject we have not yet touched on that you would like featured this year? Is the 12:15-1:15 p.m. hour still ideal for attending webinars? Please send your feedback to email@example.com.
Thank you for your patience and your continued support of the CMA webinar program.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from Peggy Stilley, the Director of ICD-10 Development and Training for AAPC, a training and credentialing association for the business side of health care.
As implementation of the ICD-10 code set approaches on October 1, 2015, physicians should examine their current clinical documentation. An efficient way to accomplish this is to perform documentation assessments.
Generate a frequency report based on ICD-9 codes reported for the practice or the physician over the most recent two to three months. Next, gather a set number of records associated with these diagnosis codes and review the current documentation to determine compliance with the new code set. In this way, the practice can identify where documentation is complete and compliant, and where documentation may need to be improved.
Documentation is an official record of the medical care or treatment provided to a patient, and a means of demonstrating medical necessity for encounters, diagnostic services and surgical procedures. Relevant details of any patient encounter include risk factors, chronic conditions managed and how the patient is responding to any current treatment. The information must be recorded in a complete, accurate and timely manner.
Specificity in the medical record—such as anatomic location, time parameter (acute, chronic, recurrent), and laterality (left, right, unilateral)—will improve clinical documentation. These concepts can easily be added to the documentation template, whether the physician uses an electronic health record or a paper template. Clinical documentation improvement (CDI) is an ongoing process, not a one-time assessment. CDI will require follow-up assessments to verify that clinical concepts are being captured in documentation.
Example A: A 7-year-old boy was brought in with symptoms of cough, sore throat, fever of 102Ëš and runny nose. A rapid antigen test was positive for influenza A.
ICD-10 coding: J09.X2 Influenza due to identified novel influenza A virus with other respiratory manifestations
In this example, the patient is diagnosed with Influenza A. This is one of the three subcategories in ICD-10, broken down by the type of virus and respiratory manifestations (cough, sore throat, fever, runny nose).
Example B: Patient presents with a fracture of the right humeral shaft. Fracture was reduced and cast placed.
ICD-10 coding: S42.301A Unspecified fracture of shaft of humerus, right arm, initial encounter for closed fracture
In ICD-10, clinical concepts for fractures require documentation of:
- Location of the fracture
- Type of fracture
- Open or closed
- Displaced or non-displaced
- Episode of care
In Example B, the right humeral fracture (location, laterality) is documented but does not identify the type of fracture, which results in the use of an “unspecified” code. In Example C below, the type of fracture is documented and a specific code can be assigned.
Example C: Patient presents with oblique fracture of the right humeral shaft. Fracture was reduced and cast placed.
ICD-10 coding: S42.331A Displaced oblique fracture of shaft of humerus, right arm, initial encounter for closed fracture
ICD-10 implementation is manageable, if started early and done systematically. Don’t try to address all documentation deficiencies at once, or the task may seem daunting. Start with concepts that are used frequently and can be easily addressed; for instance, laterality or anatomic location. ICD-10 implementation will be a team effort and should involve all members of the practice staff.
“Thank you for helping us, CMA’s Center for Economic Services. We are truly blessed to have you!”
Medical Secretary/Compliance/Privacy Officer
Harold Tarleton, M.D.
CMA member since 1973
ANTHEM BLUE CROSS: Anthem Blue Cross has recently incorporated changes to its contracted Provider Claim Escalation Process. The changes, touted as improvements to streamline the escalation process and response, include the ability to request the assistance of a Provider Care Supervisor to address your inquiry if the initial representative fails to resolve the issue. Blue Cross advises that all claim inquiries must now be handled via the escalation process within Provider Care initially; Network Relations will only assist with issues that have been addressed through the Provider Care escalation process. For additional information or questions, please contact the Anthem Network Relations Team at CAContractSupport@anthem.com.
MEDICARE: Noridian will be hosting a webinar on February 11, 2015, at 11 a.m. regarding Medicare as a secondary payor (MSP). The 90-minute presentation will include discussions on MSP compliance, benefit coordination, and recovery and MSP calculations. To sign up for the webinar, visit the Noridian "Workshops" page at https://med.noridianmedicare.com/web/jeb/education/training-events.
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.