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:
- United Healthcare fails to provide proper notification on rollout of clinical data submission protocol
- New CMA resource clarifies prohibitions on balance billing Medi-Medi patients
- Free CME: CMA hosts webinar on pain management and safe prescribing
- Chronic pain and opioid treatment guidelines for injured workers now in effect
- Know Your Rights: Making the most out of your appeals
- Webinar to provide overview of CHPI Physician Quality Rating Program
- Have you received a request to confirm provider directory information from BetterDoctor?
- The Coding Corner: ICD-10 raises the diagnosis coding stakes on Oct. 1
United Healthcare fails to provide proper notification on rollout of clinical data submission protocol
The California Medical Association (CMA) is concerned that United Healthcare (UHC) failed to properly notify physicians before implementation of its Clinical Data Submission Protocol. Although California law (California Insurance Code §10133.65 and Health & Safety Code §1375.7) requires payors to provide contracted physicians with the 45 business days’ advance notice of any material contracting changes, UHC's only notification to physicians about this new protocol was in its Network Bulletin.
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. UHC has stated, however, that it will help practices establish the transmission method that works best with their current capabilities.
At the request of CMA, UHC delayed the expansion of its Clinical Data Submission Protocol in California. Originally scheduled to take effect July 1, 2016, the expansion was pushed back until September 2. However, CMA believes UHC is not compliant with state law as it has not formally notified all affected physician practices of changes to the protocol. CMA is evaluating its next steps and will update physicians when additional information is available.
While UHC lauds the sharing of clinical patient data as an opportunity to support quality and cost-effective patient care, CMA is also concerned about the administrative burden of the protocol and the impact on physician practices.
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, or contact either the UHC Provider Call Center at (877) 842-3210 or their local UHC Network Account Manager or Provider Advocate.
Click here to view the letter to UHC.
The California Medical Association (CMA) often receives questions from physician members regarding the ability to collect the 20 percent that Medicare does not cover when the physician is not a Medi-Cal provider, but provides services to Medi-Medi (Medicare/Medi-Cal) patients.
Both state and federal laws provide broad protections to such individuals and prohibit billing a Medi-Cal patient in most circumstances. Running afoul of these laws can put you at risk of a CMS audit and sanctions.
Acute and chronic pain affects large numbers of Americans, with at least 116 million adults in the United States burdened by chronic pain. In recognition of National Pain Awareness Month, the California Medical Association (CMA) is offering a webinar on September 14, intended for clinicians interested in the fundamentals of treating pain. Participants will improve their knowledge and skills in pain assessment and management, including safe prescribing and effective opioid treatment. This one-hour webinar is free to CMA members ($99 for non-members). The program will offer 1 CME credit*.
Participants will learn to identify therapeutic options for pain management and understand pain as a complex biopsychosocial phenomenon. Participants will also learn to describe and identify compliance with clinical guideline approaches to safe prescribing of opioid analgesics, including risk management strategies and development of treatment goals.
Albert Ray, M.D., is board-certified in pain medicine, psychiatry and neurology, and has been involved in the study and treatment of painful disorders for over 40 years. He is medical director of The LITE Center and Clinical Associate Professor at the University of Miami Miller School of Medicine in Florida.
Lee Snook, Jr., M.D., is board-certified in anesthesiology, internal medicine, addiction medicine and pain medicine, and is the medical director, president and founder of Metropolitan Pain Management Consultants, Inc., in Sacramento. Dr. Snook is also the vice speaker of the CMA House of Delegates.
Participants should register at least one hour before the webinar. If you do not register an hour before the webinar start time, we cannot guarantee your attendance.
To register, click here.
Contact: CMA Member Help Center (800) 786-4262 or firstname.lastname@example.org.
*The California Medical Association/Institute for Medical Quality (CMA/IMQ) is accredited by the Accreditation Council on Continuing Medical Education (ACCME) to provide continuing medical education for physicians.
The California Medical Association/Institute for Medical Quality (CMA/IMQ) designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
On-demand webinars are not available for CEU or CME credits.
The California State Division of Workers’ Compensation’s (DWC) new guidelines on the treatment of chronic pain and opioid prescribing for injured workers went into effect on July 28, 2016. The guidelines include best practices and universal precautions for safe and effective prescribing of opioids for pain due to a work-related injury.
According to DWC, the new guidelines encourage safer prescribing of opioid pain relievers with the primary goal of significantly reducing the rate of opioid-related adverse events and substance misuse and abuse.
Since 2014, the California Medical Association (CMA) has provided input to the DWC on the complicated issues related to prescription opioid misuse and overdose, based on CMA’s support for a well-balanced approach to opioid prescribing and treatment that considers the unique needs of individual patients. CMA has published two white papers for physicians on prescribing opioid medications; both are available in CMA's online resource library.
- Opioid Analgesics in California: Relieving Pain, Preventing Misuse, Finding Balance
- Prescribing Opioids: Care and Controversy
CMA’s Institute for Medical Quality also frequently hosts continuing medical education in pain management. To find out about available courses, click here.
For more information on safely and effectively prescribing controlled substances for pain, see CMA's safe prescribing resource center at www.cmanet.org/safe-prescribing.
Thanks to California Medical Association (CMA)-sponsored legislation (AB 1455) and the resulting regulations, payors are required to have a fast, fair and cost-effective dispute resolution mechanism (i.e., “appeal process”) to resolve provider disputes. Anytime a payor contests, adjusts or denies a claim, they are required to advise the provider of the availability of the appeal process and instructions for submitting the appeal.
Payors are also required to acknowledge receipt of a written appeal within two working days for electronic appeals or 15 working days for paper appeals. The payor is required to respond to written appeals submitted by providers within 45 working days of receipt, and they must report to the Department of Managed Health Care, on an annual basis, the nature and volume of appeals received [28 C.C.R SS1300.71.38 (e)(f)(k)].
While these requirements provide safeguards for verification of receipt and timely review of your appeal, physicians still face numerous challenges when pursuing the appeal process. To overcome these challenges and make the most out of your appeals, CMA recommends the following:
- Clearly state in the subject line and first sentence of your appeal letter that this is an “APPEAL.” Steer clear of the word “inquiry” in your appeal. Use of the word “appeal” leaves no doubt about your intention – to appeal the payment (or non-payment) of the claim – and will ensure the appeal gets to the right department and will be responded to in writing within the required timeframes.
- Make sure you are sending your written appeal to the correct address. Some payors, such as Blue Shield, have a different P.O. Box for claims vs. appeals. If you send your written appeal to the claims address, it will likely be processed as an “inquiry” and not an appeal, which means you may not receive a written response, let alone the desired outcome of reprocessing of your claim.
- Clearly state your “ask,” ideally at the beginning and the end of your letter. For example, are you asking that the bundling edits be re-reviewed, are you asking for a medical necessity appeal to be reviewed by a physician of same or like specialty, or are you disputing the payor’s claim that the patient wasn’t eligible? Simply venting about your frustration with how a claim was denied incorrectly or underpaid isn’t enough to communicate why you believe the claim was processed incorrectly or what action you are requesting in your appeal.
- Look out for the written acknowledgement of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received it. If you don’t receive the acknowledgement of receipt, there is likely a problem and a phone call to the payor may be in order.
- Look out for the payor’s written response to your appeal that should include the pertinent facts and reasons for its determination, which should arrive within 45 working days of receipt of the appeal.
If the payor upholds its decision on the first level of appeal, pursue a second or final level appeal (if available). Review the payor’s first level determination and provide any additional information or relevant details in support of your argument.
Don’t forget that CMA members and their staff can contact CMA’s practice management experts at (888) 401-5911 or email@example.com for assistance. If you don’t receive the acknowledgement or written response from the payor, or if you feel the dispute process has failed, please give us a call. We are here to help!
With the California Healthcare Performance Information System (CHPI) publishing clinical quality ratings for approximately 13,000 California physicians later this year, physicians will soon begin receiving notices advising of their quality scores, along with information on how to access the review and corrections portal to confirm or correct their data.
Pacific Business Group on Health (PBGH) senior managers Emily London and Pete Sikora will present a webinar overview of the CHPI quality rating project, along with step-by-step instructions on how physicians can review their data for accuracy before the quality scores are published. This webinar, free to CMA members, will take place October 5, 2016, from 12:15 to 1:15 p.m. The cost for nonmembers is $99.
Click here for more information or to register.
The California Medical Association (CMA) has received an increasing number of inquiries over the past few weeks from practices concerned about the validity of requests for information from a company called BetterDoctor.
SB 137, the new provider directory accuracy law, took effect July 1. The new law requires payors to ensure that their physician directories are accurate and up-to-date. BetterDoctor is a vendor working on behalf of 10 plans on a pilot project to ensure the accuracy of their physician directories, as required under the new law.
Practices are encouraged to respond to the information requests, as the law also requires physicians do their part to keep their information up-to-date. (Click here to see the BetterDoctor template information request.)
The ten plans included in the pilot are AltaMed, Anthem Blue Cross, Blue Shield of California, CareMore, Health Net of California, Humana, LA Care, Molina Healthcare, SCAN and Western Health Advantage. For more information on the pilot, click here. There may also be other pilot programs taking place on behalf of other payors that utilize other vendors.
For more information about physicians’ obligations under SB 137, see CMA's new resource, “What Physicians Need to Know to Avoid Penalties Under the New Provider Directory Accuracy Law."
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 first annual update for the ICD-10-CM code set becomes effective October 1, 2016, bringing with it over 1,900 new diagnosis codes and many hundreds of code revisions and deletions. More concerning, however, the same date marks the end of the ICD-10 coding “grace period,” which may significantly affect payment for your Medicare claims.
When ICD-10 became effective October 2015, the Centers for Medicare & Medicaid Services (CMS) granted a concession to ease the transition from ICD-9. For one year, CMS said it would not reject or audit Medicare Part B claims based solely on diagnosis coding, as long as the ICD-10 code(s) submitted were from the appropriate code family. In other words, “close enough” was good enough, and claims would be paid even if a provider’s diagnoses lacked the level of specificity that ICD-10 requires.
For example, within ICD-10 the three-digit code M05 describes “Rheumatoid arthritis with rheumatoid factor.” The code requires a fourth digit to describe potential complications (e.g., Felty’s syndrome, rheumatoid lung disease, etc.); a fifth digit to describe joint involvement; and a sixth digit for laterality (e.g., left, right or bilateral). Within the one-year grace period, a provider could correctly diagnose and code rheumatoid arthritis with rheumatoid factor but assign the fourth, fifth and sixth digits incorrectly—or not at all—and still receive payment from Medicare.
The upcoming end of the ICD-10 grace period means that Medicare will reject claims that lack diagnosis accuracy and specificity, which could affect reimbursement. Per CMS, “providers should already be coding to the highest level of specificity…. As of October 1, 2016, providers will be required to code to accurately reflect the clinical documentation in as much specificity as possible, as per the required coding guidelines.”
Rather than wait until denials pile up, providers must be proactive to document diagnoses and assign diagnosis codes correctly. CMS advises that providers determine which codes affect their practices, and focus on clinical concepts behind those codes. For instance, to return to the earlier example of rheumatoid arthritis with rheumatoid factor, the relevant clinical concepts are related complication, joint involvement and laterality. If the provider documents those key concepts, selecting a detailed diagnosis is straightforward. But if any of those concepts are missing, the claim faces rejection.
Make a list of the most common diagnosis “families” in your practice or facility, and determine which clinical concepts are required to document those conditions to the greatest level of specificity. If you’re using an electronic health record (EHR), be sure your software is up to date and able to handle the code changes scheduled for Oct. 1. When properly designed or customized, the EHR may be able to prompt the provider to supply necessary details to support code specificity.
CMS also advises against assigning “unspecified” ICD-10 codes “whenever documentation supports a more detailed code.” Unspecified codes are appropriate only when a greater level of detail cannot be determined:
You should code each health care encounter to the level of certainty known for that encounter. When sufficient clinical information is not known or available about a particular health condition to assign a more specific code, it is acceptable to report the appropriate unspecified code (for example, a diagnosis of pneumonia has been determined but the specific type has not been determined).
Check the coding on each claim to make sure that it aligns with the clinical documentation. For example, examine individual instances or patterns of unspecified code use so you can determine what information or steps you’re missing to assign a more specific code.
If you’re holding onto ICD-9—for instance, using General Equivalence Mappings (GEM) to “translate” your most common ICD-9 codes to ICD-10—it’s time to move on. GEMs cannot always translate accurately from one code set to another (and in many cases, no such translation is possible). It is both more accurate and more efficient to assign ICD-10 codes directly from the record.
Assigning diagnoses to the highest level of specificity takes time, but productivity will improve as providers and their staff become more familiar with the code set. And, by documenting completely and choosing codes correctly the first time, providers can limit the (far greater) time and expense of rejected claims, amending or correcting documentation and claims after the fact, payment appeals, negative audit results and more.
MEDI-CAL: Medi-Cal claims that do not meet the ordering, referring and prescribing (ORP) provider requirements of the Affordable Care Act are currently receiving warnings on their Remittance Advice Detail forms indicating code 0558: The ORP Provider is not enrolled. Claims indicating this code require the provider to take corrective action to become compliant and to correct current claims while preventing future denials. Providers seeking additional information regarding ORP can access the Department of Health Care Services’ Ordering/Referring/Prescribing brochure, available on the Medi-Cal website.
UNITED HEALTHCARE: Effective November 1, 2016, for participating United Healthcare (UHC) providers, and August 1, 2016, for non-participating providers, UHC will implement a new reimbursement policy for UHC Commercial and Medicare Advantage laboratory claims. The new policy will require that all laboratory service claims billed on a CMS-1500 claim form or through an electronic 837 P claim file indicate the Clinical Laboratory Improvement Amendments (CLIA) number of the laboratory care provider. Additionally, the laboratory care provider’s physical address also will be required if the address differs from the billing provider’s address noted on the claim. The billing or servicing provider address must match the address associated with the CLIA ID number.
Claim Format and Elements
CLIA Number Location
Ordering Provider Name and NPI Number Location
Servicing Laboratory Physical Location
Ordering provider name in field 17 and NPI number in field 17b
If the servicing address is not equal to the billing provider address:
Indicated in the 2300 loop, REF02 element
Ordering provider name and NPI number in 2310A loop, NM1 segment
If the servicing address is not equal to the billing provider address:
Claims for laboratory services may be denied if the CLIA information is missing or invalid. Claims that are denied for missing information may be resubmitted to UHC with the required information for reprocessing.
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.
9/14: Understanding Pain Management and Safe Prescribing Practices: Acute and chronic pain affects large numbers of Americans, with at least 116 million adults in the United States burdened by chronic pain alone. In recognition of National Pain Awareness Month, the California Medical Association (CMA) is offering a webinar intended for clinicians interested in the fundamentals of pain and to improve knowledge and skills in pain assessment and management, including safe prescribing and effective opioid treatment. Participants will learn to identify therapeutic options for pain management and understand pain as a complex biopsychosocial phenomenon. Participants will also learn to describe and identify compliance with clinical guideline approaches to safe prescribing of opioid analgesics, including risk management strategies and development of treatment goals.
9/28: 2016 Ballot Measures: How Your Vote Can Increase Access to Care: In 2016, the California Medical Association (CMA) is taking the issue of Medi-Cal funding to the people through two ballot measures: Prop. 55 and Prop. 56. This webinar will present an overview of the 2016 ballot initiative campaigns in which CMA is involved, with a focus on their impact on patient access to care and the state of health care in California. We will also briefly review other initiatives CMA has taken a position on.
10/5: CHPI Physician Quality Rating Program: Navigating the Review and Corrections Process: With the California Healthcare Performance Information System (CHPI) publishing clinical quality ratings for approximately 13,000 California physicians later this year, physicians will soon begin receiving notices advising of their quality scores along with information on how to access the review and corrections portal to confirm or correct their data. This webinar will provide an overview of the CHPI quality rating project, along with step-by-step instructions on how physicians can review their data for accuracy before the quality scores are published.
Upcoming CMA seminars
CMA experts travel to local county medical societies throughout the state, holding live seminars for members and their staff on a variety of issues.
9/13: Riverside County Medical Association (Murrieta): Practice Management 101
9/20: Riverside County Medical Association (Palm Springs): Practice Management 101
9/28: San Mateo County Medical Association: Contract Renegotiation: How to get past no with a payor
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.