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.
- SUBSCRIBE NOW: Sign up now for a free subscription to our email bulletin.
- SPREAD THE WORD: Please share this bulletin with your coworkers and colleagues.
- QUESTIONS: Contact us with your questions about articles in this issue.
- TELL US WHAT YOU THINK: CMA is interested in your feedback.
- PRINT: Download a printable version of this newsletter.
In this issue:
- Be prepared for Covered California changes in 2016
- Anthem Blue Cross providers can now update demographics electronically
- Noridian conducting numerous prepayment reviews
- United Healthcare to offer webinars to physicians participating in Core Network
- Anthem Blue Cross delays implementing utilization review for physical therapy and
- Ask the expert: If an exchange patient is in the 90-day grace period and fails to pay
the premium, is the plan required to pay for services provided?
- Governor signs bill to extend CURES registration deadline for prescribers and dispensers
- Providers who refer, order or prescribe for Medi-Cal beneficiaries must enroll with DHCS
- Blue Shield fee schedule changes took effect November 1
- Are you signed up for Medi-Cal’s Subscription Service?
- The Coding Corner: Decision for treatment calls for separate E/M reporting
In 2015, Covered California, California's health benefit exchange, enrolled approximately 1.3 million individuals in qualified health plans. With Covered California estimating it may enroll an additional 300,000-plus during the 2016 open enrollment period (running November 1, 2015, through January 31, 2016), and two new plans in the mix, it is critical that physician practices understand their participation status, which products are being offered and what changes to expect in 2016.
To help physicians understand the changes taking place and how they will affect their practice, the California Medical Association (CMA) has published a new tip sheet, “Surviving Covered California: Preparing for changes in 2016.”
The tip sheet is available free to members at www.cmanet.org/exchange.
Anthem Blue Cross announced in its October Network bulletin that providers can now update their demographic information via the Availity web portal. Practices can now submit online changes for their practice profile, including the following:
- Name changes
- Address and phone/fax changes
- Tax ID changes
- Providers leaving a group
- Opening/closing a practice location
To submit changes electronically, use the Provider Maintenance Form, located on the Availity website. The form can be found in the Availity web portal main menu under Payer Resources Page > Anthem > Physician Change Requests/Provider Maintenance Form. Once changes are submitted, practices will receive an auto-reply e-mail acknowledging receipt of their request. Updates to provider demographic or practice information may take up to 20 days to be reflected in the Provider Finder.
Providers may also use this process to initiate a contractual termination; however, Anthem advises that providers submitting a notice of contractual termination must provide at least 120 days advance notice.
For more information on how to submit provider demographic updates to the major payors in California, see CMA's resource, "Updating Provider Demographic Information with Payors," available free to CMA members on our website.
Noridian, California's Medicare Administrative Contractor, recently announced that it is conducting a targeted audit of code 45378 (colonoscopy). On October 21, 2015, Noridian announced it is adding several more audits to the list, including G0439 (annual wellness visit), 78452 (SPECT), 70553 (MRI of the brain ) and 76700 (abdominal ultrasound).
Noridian Part B Medical Review conducts these targeted reviews based on national and local data in conjunction with the findings from Comprehensive Error Rate Testing to identify atypical billing.
All of the reviews are being conducted on a pre-payment basis, meaning Noridian will notify physicians selected for claim audits through the additional documentation request (ADR) process before payment is made. Upon receipt of a request for information, practices must submit all applicable documentation for each claim with a copy of the ADR as a cover sheet. Records should be mailed (hardcopy or CD) or faxed to Noridian within 45 days of receipt of the request, or a claim denial will result. Noridian also accepts records via Medicare's Electronic Submission of Medical Documentation (esMD) transactions.
For detailed information regarding these reviews and required documentation, click here. For more assistance on signature and documentation requirements, refer to the Documentation Guidelines for Medicare Services on Noridian’s website.
Documentation that may support the services billed includes:
- Legible copy of the patient's medical record for listed date(s) of service
- Legible physician signature
- Consultation reports
- Physician progress notes
- Diagnostic test results/reports
- Any other documentation to support the CPT code that was billed
Noridian will review the documentation submitted within 30 days of receipt. No letters will be sent on the outcome of each individual claim. The claim decisions will be reflected in the remittance advice and may be appealed through the normal appeal process, if unfavorable.
When the audit is complete, Noridian will analyze the results and determine if any subsequent actions are necessary. The results will be posted to Noridian’s JE Part B website.
As announced earlier this year, United Healthcare (UHC) will begin offering products through Covered California, the California health benefit exchange, in 2016. In April, UHC notified 19,000 of its commercially contracted physician practices of their inclusion in the newly created UHC Core product line designated as its Covered California provider network.
In 2016, UHC will only offer exchange coverage in the five regions of California where fewer than three exchange health plans are currently offered, including:
- Region 1: Northern counties (Alpine, Amador, Butte, Calaveras, Colusa, Del Norte, Glenn, Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter, Tehama, Trinity, Tuolumne and Yuba)
- Region 9: Central Coast (Santa Cruz, San Benito, Monterey)
- Region 11: Central Valley (Fresno, Kings, Madera)
- Region 12: Central Coast (San Luis Obispo, Santa Barbara and Ventura counties)
- Region 13: Eastern region (Inyo, Mono)
UHC will be sending a welcome packet to Core participating physicians and is offering a number of one-hour webinars aimed at providing more information about the United Healthcare Core for the Health Insurance Marketplace product. The welcome packet will be sent out mid-November, but practices can register to attend a webinar now. Topics included are health plan overview, eligibility and benefits details, how to verify participation status, and prior authorization requirements.
To register for one of the webinars, visit www.UnitedHealthcareOnline.com > Tools & Resources > Products & Services > 2016 Health Plans Training. Physicians who are unsure about their participation in the Core plan network can contact UHC Network Management at (866) 574-6088.
Anthem Blue Cross delays implementing utilization review for physical therapy and occupational therapy
Anthem Blue Cross has delayed implementing its physical therapy and occupational therapy utilization management program for outpatient and office-based services originally scheduled to go into effect on November 1, 2015. A new effective date has not yet been announced.
Anthem has contracted with OrthoNet LLC, a leading musculoskeletal management company that has experience working with physical and occupational therapists, to handle the utilization process. Pre-certification will soon be required for all outpatient and office physical and occupational therapy services for Anthem Blue Cross members, except for the following health benefit plans:
- Medicare Advantage
- Medicare Supplement
- Medicare Part D
- Anthem National Accounts (ANA)
- ASO – Self Funded Groups
- Federal Employee Program (FEP)
- Blue Card
An FAQ document detailing the clinical policies and procedures for providers providing therapy services to Anthem members, as well as links to the required forms, can be found on the Orthonet website. When the program does become effective, precertification requests should be submitted to OrthoNet via fax at (844) 349-7496 or by contacting the Orthonet Call Center at (844) 691-4062.
Ask the expert: If an exchange patient is in the 90-day grace period and fails to pay the premium, is the plan required to pay for services provided?
Maybe. Under the Affordable Care Act, exchange enrollees who receive federal premium subsidies to help pay their premiums are entitled to keep their insurance for three months after they have stopped paying their premiums. Insurance ID cards for exchange enrollees do not indicate whether the enrollee is subsidized, but Covered California recently reported that 90 percent of California exchange patients are receiving subsidies, so the likelihood of encountering a patient receiving subsidies is very high.
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.
However, in 2014, the California Medical Association (CMA) was successful in advocating that plans be required to clearly communicate 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, you need to 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.
If a plan requests a refund for services provided during the first month of the grace period, practices should dispute the request in writing, citing California Code of Regulations section 1300.65.2 (b)(1)(A), which requires plans to pay for services incurred in the first month of the grace period. Practices should also contact CMA so that we can identify any systemic issues with the payor.
If a plan requests a refund on a patient who was in the second or third month of the grace period, but the eligibility verification did not reflect suspended coverage, the plan is not entitled to the refund. The practice should submit a written dispute to the plan citing California Code of Regulations section 1300.65.2(d)(5). Again, please contact CMA if this happens, so we can identify any systemic issues.
For more information, visit 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 firstname.lastname@example.org.
In the final days of the legislative session, the California Medical Association (CMA) worked to pass Assembly Bill 679 to extend the deadline that would require physicians who prescribe controlled substances to register for the Controlled Substance Utilization Review and Evaluation System (CURES). 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 (DEA Certificate) now have until June 30, 2016, to register to use CURES.
In 2013, Senate Bill 809 required the California Department of Justice (DOJ) to identify and implement a streamlined application and approval process for CURES registration. Currently, the registration process remains highly manual, requiring notarization of documents and reportedly six to eight weeks to process applications. A streamlined process was seen as essential to meeting the January 1, 2016, registration deadline. DOJ has not issued a definite date for when streamlined registration will be available, which is why CMA pursued an extension. The bill was signed into law on October 11, 2015.
CMA will continue to monitor the situation, communicate with DOJ and update members on progress. CMA recommends that any physicians who need access to CURES not wait for streamlined registration and begin the process for registration as soon as possible.
Under the Affordable Care Act, all providers who order, refer or prescribe (including but not limited to physicians, nurse practitioners and physician assistants) for Medi-Cal beneficiaries must be enrolled in the Medi-Cal program. Previously, providers needed to enroll only if they wished to furnish (and bill for) covered services for Medi-Cal beneficiaries.
If an ordering and/or referring provider (ORP) is not enrolled in Medi-Cal, the "filling providers" (for example, the pharmacy that is filling the patient’s prescription or the specialist you are referring a patient to for treatment) will not be paid. As a result, patients may not receive needed items or services if the “filling providers” refuse to accept orders or referrals from providers who are not enrolled in Medi-Cal.
Although the new requirement went into effect January 1, 2013, the California Department of Health Care Services (DHCS) established a grace period to allow more providers to enroll before turning the edit on and denying claims. During this grace period, DHCS has been issuing a Remittance Advice Determination (RAD) code of 0556, “ORP prov not enrolled, correct or future claims will not pay” to “filling providers.”
DHCS reports that a high number of ORPs have still not enrolled with DHCS, thus threatening payment to “filling providers” once the ORP edit is turned on in its system. While DHCS hasn’t yet started denying claims, the grace period could end at any time. Ordering and/or referring providers are therefore encouraged to complete the enrollment process as soon as possible. Additionally, practices that are seeing code 0556 on their RADs should reach out to the ORP about enrolling.
ORP providers are providers who enroll for the sole purpose of ordering, referring or prescribing to covered beneficiaries and who do not directly submit claims for their services. Please note that this type of enrollment does not allow the Medi-Cal program to reimburse the ORP—only providers who provide services directly to Medi-Cal beneficiaries.
Providers who are already enrolled in Medicare or Medi-Cal under their individual (type 1) National Provider Identifier (NPI) number do not also have to enroll as ORP providers.
Providers that may be affected by this change include individual physicians or physicians employed by physician groups, federally qualified health centers, rural health clinics, critical access hospitals, the Department of Veterans Affairs, Department of Defense TRICARE program and the Public Health Service.
For questions regarding enrollment as an ORP provider, contact the DHCS Provider Enrollment Division at email@example.com or (916) 323-1945.
In August, Blue Shield announced changes to its physician fee schedule that became effective November 1, 2015. In a notice sent to physicians, the insurer said that it was increasing payments for the more commonly billed office visit codes.
The new rates are available on the Blue Shield website (go to www.blueshieldca.com/provider and log in, then select the “Professional Fee Schedule” link located under the "Claims" section menu). Physicians can also request a copy of the new fees by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Services Department at (800) 258-3091.
To help physicians understand their rights when a health plan has sent notice of a material change to a contract, the California Medical Association (CMA) has published “Contract Amendments: an Action Guide for Physicians,” available in CMA's online resource library. The guide includes a discussion of options available to physicians when presented with a material change to a contract. Additionally, the guide includes a financial impact worksheet that will help physicians calculate the net impact of the fee schedule changes on their practices.
Click here to view a copy of the notice that was recently sent to physicians.
The California Department of Health Care Services (DHCS) last year launched the Medi-Cal Subscription Service (MCSS). Subscribers can sign up to receive monthly digest bulletins and/or as-it-happens "news flashes" for critical or time-sensitive issues. You can tailor your subscription to receive only information on subject matters of interest to you and your practice, including billing, payment and policy rule changes.
Subscriptions are free. To sign up, go to www.medi-cal.ca.gov/mcss, select the subject matter areas of interest, and fill in your email and zip code.
To help providers more easily access important policy and program changes, the following enhancements have also been added to the Medi-Cal website:
- NewsFlash tab: The Newsroom tab is now named “NewsFlash.” Links to NewsFlash articles will be emailed to MCSS subscribers who choose to receive these notifications.
- Monthly bulletins tab: Providers may access the monthly Medi-Cal Updates within the new “Monthly Bulletins” tab, or by clicking the “Bulletins” link within the “Featured” area on the Medi-Cal home page. The tab name will change on a monthly basis to indicate the month of the most recent bulletins. Bulletins are posted on or before the 16th of every month.
- MCSS page: On the MCSS page, providers can subscribe to receive email messages that include direct links to NewsFlash articles, Medi-Cal Update bulletins and/or Systems Status Alerts. Providers may access the MCSS page via the “Publications” tab or the MCSS link in the “Featured” area.
- Beneficiary News link and page: The “Beneficiary News” link in the “Featured” area leads to the new “Beneficiary News” page, which includes links to important beneficiary information. This page can also be accessed from the “References” page.
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.
CPT® and the Centers for Medicare and Medicaid Services (CMS) guidelines state that all procedures (even the most basic) should include an inherent evaluation and management (E/M) component.
For example, a patient is scheduled to receive a simple injection in the office. A provider meets with the patient to asses her or his fitness to receive the injection, discuss risks and benefits of the injection, and answer basic questions. This work is “bundled,” or included as part of the global service fee for the injection administration, and may not be billed separately. The same rules apply, for instance, when an operating surgeon assesses a patient prior to surgery; the pre-operative assessment is included in payment for the surgical procedure.
What you may report separately, however, is the E/M service during which the physician determines that further treatment is medically necessary.
For instance, the provider records a relevant history and exam, and considers treatment options for a patient with knee pain and swelling. This is a billable E/M service, which may be reported in addition to any medically necessary procedures at the same visit (e.g., x-ray, aspiration to reduce swelling, injection for pain relief). The E/M service is not incidental in this case, but is essential to determine the need for the diagnostic or therapeutic care that follows.
To bill successfully in these circumstances requires both adequate documentation and proper modifier application when submitting the claim.
Ideally, providers should separate their E/M service documentation from that of any other procedure(s) or service(s). For example, the provider could document the history, exam and medical decision-making in the patient’s chart, and record the procedure notes on a different sheet attached to the chart or in a different section within the electronic health record. This demonstrates to the payor and coding staff the distinct nature of the E/M service.
CMS classifies non-E/M procedures as either “major” or “minor.” This information is crucial to determine when you should append a modifier to an E/M service and, if so, which modifier is correct.
In simple terms, major procedures are those with a 90-day global period. All other procedures (e.g., those with a zero-day, 10-day, or other assigned global period) are minor procedures. You can find a global period look-up tool on the CMS website here.
If the provider furnishes a minor procedure and a separate E/M on the same date of service (at the same or a separate encounter), you must append modifier 25 Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service to the E/M service code.
CPT Assistant (May 2011) provides an example:
A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child’s pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure.
This procedure would be reported 13132 Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management (E/M) service performed in addition to the wound repair would be reported separately using modifier 25.
Choose modifier 57 Decision for surgery—rather than modifier 25—to report a separately identifiable E/M service that occurs on either the same day or the day before, a major surgical procedure, and that results in the decision to perform the surgery, according to the Medicare Claims Processing Manual, section 40.2.
For example, a patient arrives at the emergency department with acute appendicitis, and is taken to surgery. The surgeon performing the surgery may report an E/M service code for the evaluation and history and physical (H&P). Append modifier 57 to the E/M service code to indicate that the E/M is not included in the surgical package.
Remember: If the provider sees the patient for a previously scheduled procedure or service, you would not normally report a separate, same-day E/M service. “Visits by the same physician on the same day as a minor surgery or endoscopy are included in the payment for the procedure, unless a significant, separately identifiable service is also performed,” confirms the Medicare Claims Processing Manual (Chapter 12, Section 40.1).
Text added to the CPT® codebook surgery guidelines in 2015 confirm that “Evaluation and management services subsequent to the decision for surgery on the day before and/or day of surgery (including history and physical)” are “included in addition to the operation per se.”
For example, a patient is seen on Feb. 1 and scheduled for surgery on Feb. 15. The surgeon sees the patient again for an H&P on the day of the surgery. Although you may report the Feb. 1 visit (with no modifier attached, as it occurs well in advance of the surgery and therefore is not included in the surgical package), you would not separately report the H&P on Feb. 15 because the decision for surgery was not made at that visit. Rather, the Feb. 15 visit is bundled into the surgical package.
ANTHEM BLUE CROSS: In response to a recent spike in referrals to non-participating workers’ compensation providers, Anthem has issued a reminder to contracted providers that referrals to a specialist or other contracted provider, hospital, ambulatory surgery center, ancillary and behavioral health provider must be within the Anthem Workers’ Compensation Network (or for employers that have a medical provider network, within that specific network). Referrals to non-participating providers could result in non-payment of a workers’ compensation bill. For assistance in identifying a contracted workers’ compensation provider, providers can contact Anthem customer service at (866) 700-2168 or visit www.bclhwcmcs.com.
UNITED HEALTHCARE: Effective January 1, 2016, United Healthcare (UHC) will require commercial members to undergo genetic counseling prior to breast cancer (BRCA) laboratory testing for mutations related to hereditary breast and ovarian cancer. UHC reports that the requirement for genetic counseling is based on recommendations issued by the U.S. Preventive Services Tasks Force as well as the National Comprehensive Cancer Network.
The counseling can be done over the phone or in an office setting; all providers administering the BRCA laboratory test will be required to show evidence that the genetic counseling requirement has been fulfilled in order to receive authorization for the test.
For more information about this requirement, visit www.UnitedHealthcareOnline.com > Clinician Resources > Oncology > Programs, Tools & Resources > BRCA Testing > Tools & Resources > BRCA Genetic Counseling Requirement Frequently Asked Questions. Additional questions can be sent via email to 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.