CMA Practice Resources (CPR) is a free monthly e-bulletin from the California Medical Association’s practice management experts that focuses on critical payor and health care industry changes and how they directly impact the business of a physician practice. Each issue includes tips on reimbursement and contracting related issues along with information on the latest practice management news.
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In this issue:
- CMA seeking physician feedback on proposed health insurance mergers
- Congress authorizes blanket exemptions from meaningful use penalties
- Technical assistance available for CURES 2.0 users
- Anthem Blue Cross to review level 5 emergency room claims
- Reminder: Exchange patients, eligibility and the 90-day grace period
- Blue Shield revises Provider Data Confirmation form
- UHC to introduce new primary care assessment program
- New approval timeframes for prescription drug prior authorizations took effect Jan. 1
- UHC to require prior authorization for select musculoskeletal and pain management procedures
- HHS modifies HIPAA Privacy Rule as part of executive actions to curb gun violence
- The Coding Corner: How to code the Medicare advance care planning benefit
Proposed mergers of the some of the largest national health insurance companies have been announced, with Aetna reaching a $37 billion deal to purchase Humana, and Anthem agreeing to purchase Cigna for $48.4 billion.
State and federal regulators are interested in knowing the prospective effects of these possible mergers on your practice and patient care. The California Medical Association (CMA), in collaboration with the American Medical Association, is asking for your feedback on these proposed mergers.
The survey should take about 8-9 minutes to complete.
Only de-identified data will be used in our reporting. It is important that we receive your feedback no later than Friday, February 12, 2016.
To complete the survey, click here.
In mid-December, Congress adopted a last-minute bill that gives CMS the authority to grant a blanket exemption for all eligible physicians who apply for the exemption from the 2015 meaningful use penalties. This action prevents the Centers for Medicare and Medicaid Services (CMS) from implementing Medicare payment penalties for physicians who fail to demonstrate meaningful use of a certified electronic health record (EHR) system in 2015.
New rules released last year state that eligible professionals must attest that they met the requirements for stage 2 meaningful use for a period of 90 consecutive days during calendar year 2015. However, CMS did not publish the updated regulations for stage 2 meaningful use until October 16, 2015. As a result, eligible professionals were not able to report until fewer than the 90 required days remained in the calendar year.
CMS had previously stated that it would grant hardship exemptions for 2015 if providers were unable to attest due to the late publishing of the rule, but law at that time only authorized it to grant such exemptions on a case-by-case basis. This new law grants CMS the authority to make an automatic exemption IF it receives a hardship exemption application. It also streamlines the exemption process, alleviating burdensome administrative issues for both physicians and the agency.
Under the new law, physicians are still required to file for a hardship exemption to avoid a payment adjustment for 2015 no later than March 15, 2016.
Physicians are urged to preemptively file for a 2015 hardship exception to avoid penalties in 2017. Physicians are encouraged to apply even if they are uncertain whether they will meet the program requirements this year. CMS has stated that it will broadly accept hardship exemptions because of the delayed publication of the program regulations. Applying for the hardship will not prevent a physician from earning an incentive; it simply protects a physician from receiving a meaningful use penalty. Therefore, physicians who believe that they met the meaningful use requirements for the 2015 reporting period should still apply for the hardship protection. Note that the program operates on a two-year look-back period, meaning that physicians who are granted an exception for the 2015 program will avoid a financial penalty for 2017.
The application is available on the CMS website and can be downloaded by clicking here. Physicians are encouraged to apply for a hardship under the “EHR Certification/Vendor Issues (CEHRT Issues)” category (option 2.2.d in the application). The American Medical Association (AMA) has published a fact sheet that includes step-by-step instructions on how to apply for the hardship exemption.
The deadlines for submitting applications for hardship exceptions are:
- Eligible physicians: March 15, 2016
- Eligible hospitals: April 1, 2016
CMA and AMA worked frantically the last few weeks of 2015 to get the bill passed authorizing this blanket exemption. CMA extends a huge thank you to Majority Leader Kevin McCarthy (R-CA) and Minority Leader Nancy Pelosi (D-CA) for agreeing to keep the House in session and pass the bill on unanimous consent.
For more information on the EHR incentive program, see the CMS tipsheet, "EHR Incentive Programs for Eligible Professionals: What You Need to Know for 2015."
On January 8, 2016, the California Department of Justice (DOJ) launched an upgrade to the Controlled Substance Utilization Review and Evaluation System (CURES), California's prescription drug monitoring system. Known as "CURES 2.0," the system promises a significantly improved user experience and features a number of added functionalities.
All users who log into CURES will be prompted to update their security information in order to confirm their account. Those users who meet specific web browser compatibility requirements will be directed to CURES 2.0, while others will be routed to the old CURES 1.0 interface. After following this security step, physicians may experience a 15-20 minute wait before being able to log into the system with their updated credentials.
Physicians who encounter technical difficulties – such as logging into their accounts, retrieving their log-in information or verifying their accounts – should contact the DOJ CURES Help Desk at (916) 227-3843 or email@example.com. Providers are also encouraged to report these technical issues to CMA's member help line by calling (800) 786-4262 or emailing firstname.lastname@example.org.
Additionally, new CURES registrants may have experienced application processing delays through January 19, as Department of Consumer Affairs’ licensing files were unavailable for maintenance activities.
All individuals practicing in California who possess both a state regulatory board license authorized to prescribe, dispense, furnish or order controlled substances and a Drug Enforcement Administration Controlled Substance Registration Certificate must be registered to use CURES no later than July 1, 2016. To register using the new automated system, visit http://oag.ca.gov/cures.
Anthem Blue Cross announced in its December Professional Network Update that, beginning January 1, 2016, it will initiate a pre-payment review of level 5 emergency department visits billed with CPT 99285 or G0384.
Anthem has advised CMA that it will focus on level 5 emergency department visits that are billed in combination with diagnosis codes that “are an unlikely combination for high level visits.” The payor will exclude claims billed with critical care, observation or inpatient admissions.
Claims with CPT codes 99285 and G0384 that are selected by Anthem for pre-payment review will be pended and, if records are not included with the claim, a request for medical records will be generated. Anthem will review the records to verify that the documentation supports the level of service billed per CPT guidelines.
Anthem has advised CMA that if it does not believe, after review of the records, that the documentation supports the level billed, it will pay the claim based on the evaluation and management (E/M) level supported. The explanation code will reflect this action.
Providers will have the ability to dispute the findings through the normal provider dispute resolution process.
Practices are reminded that under the Affordable Care Act, exchange enrollees who receive federal premium subsidies (approximately 90 percent of enrollees) to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums. In the first month of the grace period, federal law and California regulations require plans to pay for services incurred even if the patient fails to pay the premiums due by day 90 (CCR §1300.65.2(b)(1)(A)). But in months two and three of the grace period, plans can “suspend” coverage and pend or deny claims if the patient doesn’t true up on his or her premiums by day 90.
In 2014, CMA was successful in advocating that plans be required to clearly communicate to practices through their real-time eligibility and verification systems if an enrollee’s coverage is suspended during the second and third months of the grace period. Further, the regulation requires plans to reflect “suspended” coverage on day one of the second month of the grace period, and requires plans to use one of three eligibility status indicators to reflect suspended coverage – “coverage pending,” “coverage suspended” or “inactive pending investigation” (CCR §1300.65.2(b)(C)).
If a plan fails to reflect suspended coverage using one of the above indicators on day one of the second month of the grace period, and a physician provides services to a subsidized enrollee, the plan is financially responsible for the claims incurred (CCR §1300.65.2(d)(5)). However, practices must be able to prove that the plan did not comply with the regulation.
For this reason, it is extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible, and that the practices retain a printout of the eligibility verification and includes it as part of the patient’s chart. If a patient's eligibility verification comes back indicating his or her coverage is suspended, the practice can treat the situation as it would any other patient who has had a lapse in coverage. For non-emergency services, patients may be given the option to either pay cash at the time of service or reschedule to a later date.
Further, California regulations require the plan to notify any provider with an outstanding prior authorization if the patient is in months two or three of the grace period (28 CCR §1300.65.2 (d)(2)).
If the plan fails to comply with the notice requirement and the services are provided in good faith, pursuant to the authorization, the plan is responsible for paying the authorized claim(s) (28 CCR §1300.65.2 (d)(5)).
For more information, download "Covered California: Understanding the Grace Period for Subsidized Exchange Enrollees," available in CMA’s exchange resource center at www.cmanet.org/exchange. In the resource center, you can download CMA's Surviving Covered California tip sheets as well as a number of other CMA exchange resources. CMA members and their staff also have FREE access to our reimbursement helpline at (888) 401-5911 or email@example.com.
In December 2015, CMA began receiving calls from physicians who had received requests from Blue Shield of California to complete its Provider Data Confirmation form. According to Blue Shield, the requests are an effort to comply with Senate Bill 137, a new law that requires payors to maintain accurate provider directories (among other things). Blue Shield is asking that participating providers review and complete the form to indicate whether the data it has on file for each provider is accurate, incorrect or incomplete.
Some physicians, however, had expressed concern with one of the questions on the form, which asked if the doctor was “accepting NEW patients for ALL member plans.” The form then stated that choosing “no” would suppress the physician from all PPO member networks.
Physicians expressed concern with how to accurately respond to this question if they are accepting new patients, but only for the products for which they are contracted with Blue Shield. For example, if a physician was contracted for the commercial PPO product, but not for Blue Shield’s exchange product, would answering “yes” somehow obligate that physician to see exchange patients in the future? Alternatively, there was concern that if the physician answered no in this situation, that Blue Shield would remove that name from its provider directory.
CMA raised these concerns with Blue Shield and learned that that based on provider feedback, it had revised the form. Effective January 1, 2016, the question now asks whether providers are accepting new patients in all plans for which they contract. The form also now indicates that if providers choose “no,” Blue Shield will simply update its provider directory to indicate they are only accepting current patients, as opposed to removing their names from the provider directory.
For more information on SB 137 and the provider obligation to update demographic information, click here.
Questions about the Provider Data Confirmation form can be directed to Blue Shield Provider Information and Enrollment at (800) 258-3091.
In November 2015, United Healthcare (UHC) sent notice to approximately 800 contracted primary care physicians introducing them to its new educational performance evaluation program. Slated to run concurrently with the UHC Premium Designation program, primary care physicians whose claims data demonstrates a high utilization rate in one of the following measures will receive a report:
- Emergency department utilization
- Inpatient admission utilization
- Average length of stay
- Laboratory/pathology utilization
- Levels 4 and 5 visits
- Modifier 25 utilization
- Modifier 59 utilization
- UHC premium non-Tier 1 specialist visits
- Out-of-network costs for attributed patients
- Specialty physician utilization
- Radiology utilization
- Prescribing of Tier 3 (highest cost sharing) medications
- Tier 3 (highest cost sharing) pharmacy utilization by other treating physicians of attributed patients
The initial letters were mailed to physicians on November 17, 2015, and reflect a 12-month review period beginning with January 2014 dates of service. While the notice indicates that the purpose of the program is to identify and address variations in care, UHC states that the review is only informative and intended to provide feedback on the performance of the practice. According to the payor, approximately 5 percent of contracted physicians will receive a letter in this first phase of the program.
UHC states that future phases of this program will incorporate additional specialties including obstetrics/gynecology, cardiology, neurology, orthopedics, spine and surgery.
A new law took effect January 1, 2016, that requires health plans and health insurers to respond to prescription drug prior authorization requests within 72 hours for non-urgent requests and 24 for urgent requests. The law (SB 282) deems such requests to be granted if the payor fails to respond within these timeframes. A previous law (SB 866) had required a determination within two business days or the request was deemed approved.
SB 282 also requires the Department of Managed Health Care and the Department of Insurance to create a standard electronic prior authorization request form no later than January 1, 2017. Prescribers and payors will be required to use and accept this uniform electronic prior authorization form beginning July 1, 2017, or six months after the form is developed, whichever is later. Previously, SB 866 had required use and acceptance of a paper uniform prior authorization form.
A second and related law (AB 374) requires that prior authorization for prescription drug step therapy override requests be submitted in the same manner—and using the same electronic form, when available—as a prescription drug prior authorization requests. Plans and insurer must also respond to such requests within the timeframes set forth in SB 282.
Contact: CMA's reimbursement helpline, (888) 401-5911 or firstname.lastname@example.org.
As indicated in its January 2015 Network Bulletin, United Healthcare will begin requiring prior authorization for certain additional musculoskeletal and pain management procedures effective April 4, 2016. Included in the new prior authorization requirement are various arthroscopy procedures, spine-related surgeries, neurostimulators for back pain and certain foot surgical procedures. For a complete listing of procedures requiring notification, physicians can access the Advance Notification Requirements on the UHC website.
Prior authorization will be required for services performed in all places of service settings, including inpatient/outpatient hospitals, ambulatory surgery centers and office locations. 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.
Last week, the Obama Administration unveiled a number of executive actions to address gun violence in the United States, including an amendment to the Health Insurance Portability and Accountability Act (HIPAA) that would make it easier for mental health providers to disclose the identities of individuals who are disqualified from shipping, transporting, possessing or receiving a firearm.
Both the Brady Handgun Violence Prevention Act of 1993 and the Gun Control Act of 1968 prohibit gun ownership and gun sales to individuals that have been involuntarily committed to a mental institution for mental illness or drug use; found incompetent to stand trial or not guilty by reason of insanity; or otherwise determined by a court to be a danger to themselves or others or unable to manage their own affairs due to mental illness, incompetency, condition or disease.
Up until now, however, the HIPAA Privacy Rule generally prohibited mental health providers and HIPAA-covered entities from disclosing patient information to the National Instant Criminal Background Check System (NICS) – a system maintained by the Federal Bureau of Investigation to conduct background checks on people who may be legally disqualified from owning firearms based on statutorily defined federal “mental health prohibitor” categories.
Under this final rule, certain covered entities with lawful authority to make adjudications or commitment decisions that make individuals subject to the federal mental health prohibitor are permitted to disclose the information to NICS. The information that can be disclosed is limited to demographic and certain minimum necessary information needed for NICS to determine whether a potential firearm recipient is statutorily prohibited from possessing or receiving a firearm.
According to the U.S. Department of Health and Human Services (HHS), the modification better enables the reporting of these individuals to the background check system, while continuing to strongly protect individuals’ privacy interests. It also gives states improved flexibility to ensure accurate but limited information is reported to NICS.
The new rule is narrowly tailored to preserve the patient-provider relationship and ensure that individuals are not discouraged from seeking voluntary treatment. This rule applies only to a small subset of HIPAA-covered entities that either make the mental health determinations that disqualify individuals from having a firearm or are designated by their states to report this information to NICS – and it allows such entities to report only limited identifying, non-clinical information to the NICS.
The rule does not apply to most treating providers and does not allow reporting of diagnostic, clinical or other mental health treatment information.
Click here to read the final rule.
Contact: CMA's legal information line, (800) 786-4262 or email@example.com.
CPR’s “Coding Corner” focuses on coding, compliance and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.
As of January 1, 2016, Medicare covers advance care planning (ACP) as a separate service when provided by physicians and other health professionals (such as nurse practitioners who bill Medicare using the physician fee schedule). CMS enacted the new coverage as part of the 2016 Physician Fee Schedule Final Rule.
ACP is a face-to-face service that, as described by the AMA (CPT Assistant, Dec. 2014), “involves learning about and considering the types of decisions that will need to be made at the time of an eventual life-ending situation and what the patient’s preferences would be regarding those decisions.” The services include counseling and discussion of an advance directive, defined in CPT® as “a document appointing an agent and/or recording the wishes of a patient pertaining to his/her medical treatment at a future time should he/she lack decisional capacity at that time.”
Per CMS, ACP may be reported “when the described service is reasonable and necessary for the diagnosis or treatment of illness or injury.” The Final Rule provides one such example:
For example, this could occur in conjunction with the management or treatment of a patient's current condition, such as a 68-year-old male with heart failure and diabetes on multiple medications seen by his physician for the E/M of these two diseases, including adjusting medications as appropriate. In addition to discussing the patient's short-term treatment options, the patient may express interest in discussing long-term treatment options and planning, such as the possibility of a heart transplant if his congestive heart failure worsens and advance care planning including the patient's desire for care and treatment if he suffers a health event that adversely affects his decision-making capacity. In this case the physician would report a standard E/M code for the E/M service and one or both of the ACP codes depending upon the duration of the ACP service. However, the ACP service as described in this example would not necessarily have to occur on the same day as the E/M service.
CPT Assistant (December 2014) specifies additional circumstances under which ACP may be warranted:
Individuals who may need extra assistance and more skilled facilitation in making future health care decisions include: (1) individuals with end-stage chronic illness, such as congestive heart failure, renal disease, or acquired immune deficiency syndrome (AIDS); (2) individuals who, because of the timing of their illness or injury, have not been considered appropriate for ACP, such as those facing emergent and high-risk surgery, or those who experience a sudden event, such as a transient ischemic attack (TIA), and are at risk of repeated episodes; (3) individuals who have ACP needs beyond the more familiar decisions to withhold or withdraw life-sustaining treatment, such as those with early dementia or mental illness; (4) individuals who lack decision-making capacity (developmental disabilities) or authority (minors) and must rely on guardians or parents to make substitute decisions and plan for the inevitable.
The AMA introduced two new advance care planning codes in CPT® 2015:
- 99497 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes, face-to-face with the patient, family member(s), and/or surrogate
- 99498 Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; each additional 30 minutes (List separately in addition to code for primary procedure)
Code 99497 describes an initial 30 minutes of the provider’s time (face-to-face with the patient, family or surrogate). You should report only one unit of 99497 per date of service. Code 99498 reports each additional 30 minutes of service, beyond the initial 30 minutes (at least 16 minutes must pass beyond the initial 30 minutes to report 99498). For example, for 35 minutes of face-to-face ACP, proper coding is 99497; for 57 minutes of face-to-face advance care planning, proper coding is 99497, 99498 (in addition to the primary E/M service code).
Advance care planning may be provided and reported on the same day, or a different day, as other E/M services; a list of E/M codes with which you may report 99497 and 99498 is included in the CPT® guidelines preceding the code listings. Medicare also allows adding ACP as an optional element, at the beneficiary’s discretion, of the Medicare Annual Wellness Exam. Per CPT® instruction, you should not report advanced care planning on the same date of service as 99291, 99292, 99468, 99469, 99471, 99472, 99475, 99476, 99477, 99478, 99479 or 99480.
Medicare payment for ACP is approximately $85 for the first 30 minutes and $70 for each additional 30 minutes (based on 2016 Relative Value Units, before applying geographic pricing differentials).
AETNA: Effective March 1, 2016, Aetna will impose a 30-times-per-year limitation on CPT 86003 (allergen specific lgE; quantitative or semi-quantitative, each allergen). The frequency limit will be based on a rolling 12-month period beginning with the date the first service was rendered.
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.
2/10: CMA Physician Governance: How to Get Involved in CMA's Newly Reformed Governance Structure: This educational session is designed to explain CMA’s structure of physician governance and how members can get involved in the organization – especially in light of recent changes and improvements to the processes. See how your voice can impact the future of the practice of medicine in California. Ideal for members who are interested in getting involved (or more involved) in organized medicine. Open to CMA members only.
2/24: HIPAA Compliance: Key Risks All Physicians Should Know: Please join us and CMA’s HIPAA advisor, David Ginsberg, for his annual HIPAA Compliance Update. This webinar will summarize recent federal enforcement and what this means for every medical practice. We will also discuss the top HIPAA privacy and security gaps and risks, along with simple steps to comply.
3/9: Closing a Medical Practice: This webinar will cover some of the major practical and legal issues that may arise when closing a medical practice, and will assist physicians who are retiring or otherwise leaving their practices and/or families or estates of deceased physicians. Issues that will be addressed in this webinar will include people and agencies to notify when a physician practice closes, medical records retention and other issues, and considerations when selling a medical practice.
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.