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:
- Blue Shield to update fee schedule effective December 1
- Physicians encouraged to verify CHPI data by November 11
- Physicians must post nondiscrimination statements by Oct. 16
- CMS eliminates penalties for first year of MACRA and offers “pick your pace” options
- CMA to host webinar on AB 72 out-of-network billing
- Know Your Rights: Managed care contractual protections
- The Coding Corner: How to apply CPT® modifier 79
Blue Shield recently announced changes to its physician fee schedule that will take effect December 1, 2016.
The new rates are now available on the Blue Shield website (under "Helpful Resources," click “Professional Fee Schedule” then click “Search the Claims Fee Schedule”). To view the new fees, change the default date of service on the “Search Fee Schedule” page to December 1, 2016, (effective date of the change) or later.
Physicians can also request a copy of the new fees for up to 20 codes by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Information and Enrollment Department at (800) 258-3091. Blue Shield will provide a response to your inquiry within 10 business days.
As always, physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practice.
To help physicians understand their rights when a health plan has sent notice of a material change to a contract, 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 contract change, as well as a financial impact worksheet that will help physicians calculate the net impact of fee schedule changes on their practice.
In early September, approximately 13,000 physicians in California received their individual quality measurement scores for the second cycle of the California Healthcare Performance Initiative System (CHPI) quality rating program. Physicians can review and verify the accuracy of the data used to calculate their scores on the CHPI online portal through November 11, 2016.
The program rates physicians using claims data from Medicare fee-for-service, Anthem Blue Cross, Blue Shield of California and United Healthcare. This claims data includes both commercial and self-funded health plan data from HMO, PPO, POS and Medicare Advantage products.
The individual quality measurement scores were based on claims data for patient care provided January 1, 2012, through December 31, 2014. Physicians were assigned a star rating of one to four stars, based on where they fall as a percentile within a “peer group,” for each measure as well as a composite score.
Physicians who wish to verify the accuracy of the data used to calculate their scores can do so through the CHPI Review and Corrections portal. To access the review and correction portal, physicians will have to register using their username and registration token – both listed at the top left of each page of the report. Once registered, you will receive a confirmation email with instructions to create a password.
According to CHPI, it will treat the data as complete and accurate if no corrections are made. This means that even if a physician has not logged into the online portal during the review and correction period, CHPI will still publish the physician's data.
Physicians who review their data and identify errors have until November 11, 2016, to report any discrepancies via the CHPI online portal. At the close of the physician review and correction period, discrepancies will be evaluated and applied, with the results recalculated prior to the public release of the ratings. After November 11, the review and correction period will close, and physicians will be unable to review or report discrepancies.
CHPI has advised the California Medical Association (CMA) that in addition to publishing the ratings publicly, it will also release an aggregated data file to the aforementioned participating plans following the review and correction period later this year. CMA inquired as to how the data would be utilized by the plans, but as of the time of publication, it was not known.
For more information on the CHPI Cycle 2 rating methodology, visit the CHPI website at www.chpis.org. CHPI has also published an FAQ on its rating program and a step-by-step review and corrections tutorial.
Physicians who did not receive a letter but would like to confirm whether they are included in CHPI’s rating results can use the CHPI physician lookup at https://provider.medinsight.milliman.com/clients/CHPI/Public/Lookup.
If you have questions or concerns about the CHPI rating results, you may email firstname.lastname@example.org and they will respond within 48 hours.
Physicians who identify a high volume of discrepancies in the data used to calculate their scores are encouraged to contact CMA at (916) 551-2061 or email@example.com.
CMA recently hosted a webinar where CHPI staff provided an overview of the 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 is available on-demand in CMA's online resource library and is free to CMA members ($99 for nonmembers).
The U.S. Department of Health and Human Services (HHS) Office of Civil Rights (OCR) recently finalized new nondiscrimination rules intended to advance health equity and reduce health care disparities. Under the rule, which implements section 1557 of the Affordable Care Act, individuals are protected from discrimination in health care on the basis of race, color, national origin, age, disability and sex, including discrimination based on pregnancy, gender identity and sex stereotyping.
This rule applies to those who provide or administer health-related services or insurance coverage and receive "federal financial assistance." Federal financial assistance includes Medicare, Children's Health Insurance Program, Medicaid, meaningful use payments, HHS grants, Centers for Medicare and Medicaid Services gain-sharing demonstration projects, federal premium and cost-sharing subsidies, etc.
The rule does not apply to physicians who participate only in Medicare Part B, unless they are also receiving meaningful use incentive payments.
Covered physicians must comply with the following requirements:
- By October 16, post a notice of nondiscrimination and taglines in the top 15 languages spoken by individuals with limited English proficiency. (Note that this date has been corrected since this story was first published.)
- Designate a compliance coordinator and adopt grievance procedures (applicable to group practices with 15 or more employees)
- Submit an assurance of compliance form to OCR
The rule also encourages covered entities to develop and implement a language access plan to ensure they are prepared to take reasonable steps to provide meaningful access to individuals who may require assistance.
This final regulation does not, however, change current law under the Title VI regulations, which requires that any program or activity (including health care professionals) that receives federal funds must take reasonable steps to ensure meaningful access to their activities by persons with limited-English proficiency. Physicians should already be in compliance with the existing Title VI provisions required under current law, which is outlined in the California Medical Association's (CMA) On-Call document #6003, "Language Interpreters."
Physicians should note that in addition to administrative enforcement mechanisms, such as loss of federal financial assistance, individuals are permitted to bring individual or class action violation claims directly against physicians in federal court.
To assist with implementation, OCR has translated into 64 languages a sample notice and taglines for use by covered entities. In addition, OCR has published a summary of the rule, factsheets on key provisions and a list of frequently asked questions.
CMA has sought guidance from the California Department of Health Care Services to determine what languages California physicians must post for the nondiscrimination notice. Once available, CMA will publish an update.
CMA is also working on an FAQ for physicians and will be hosting a webinar on November 9 to provide more detailed instructions on complying with this rule. To register, click here or visit www.cmanet.org/events.
The Centers for Medicare and Medicaid Services (CMS) announced on September 8 that it will allow physicians to choose the level and pace at which they comply with the new MACRA Medicare payment reforms. Participating at any level in 2017 will ensure that you will not be hit with payment penalties in 2019.
The welcome announcement comes after the California Medical Association (CMA), American Medical Association (AMA) and other physician stakeholders urged CMS to ease the burdens and delay the first MACRA reporting period to give physicians more time to prepare.
MACRA (the Medicare Access and CHIP Reauthorization Act of 2015) repealed the flawed sustainable growth rate payment system, and established two payment paths: 1) A fee-for-service path that consolidates the current reporting programs under the Merit-Based Incentive Payment System (MIPS) and 2) an Alternative Payment Model (APM) path. CMS will begin measuring performance for eligible clinicians in 2017, with payments based on those results beginning in 2019.
Under the MIPS fee-for-service program, the most lenient participation option would allow physicians to simply "test" the program to ensure that their systems are working and that they are prepared for broader implementation in 2018 and beyond. While physicians who choose this option will not receive bonus payments, they will avoid a negative penalty.
Under the second option, physicians can opt to submit data for less than the full reporting year. While CMS has not yet specified the timeline, CMA believes the 2017 reporting period could be only 90-180 days. Physicians who choose this option would not only avoid a negative payment adjustment, but could receive a small bonus.
Physicians can still choose, if they are ready, to report a full year of data under MIPS in 2017 and be eligible to receive a modest bonus, depending on their performance.
The APM program is largely exempt from the MIPS criteria.
Details about the participation options will be described fully in the final rule that will be published November 1. CMA will provide additional information when available.
Click here to read the announcement.
In September 2016, Governor Jerry Brown signed a controversial bill, Assembly Bill 72, into law. This bill will change the billing practices of non-participating physicians providing non-emergent care at in-network hospitals, ambulatory surgery centers and laboratories.
The October 19 webinar will present an overview of the new law, and will help physicians understand the circumstances under which the bill applies, how physicians can continue to charge their usual and customary rates, and how the bill provides an opportunity to improve network adequacy standards.
Presented by Janus Norman, California Medical Association (CMA) senior vice president of government relations and political operations, this webinar is free to CMA members. To register, click here or visit www.cmanet.org/events.
CMA has also published an FAQ, “A Physician's Guide to AB 72: Questions and Answers” to help clarify the new law and to address the concerns and questions of CMA members.
CMA’s “Know Your Rights” series summarizes vital protections under state and federal law that physicians should be aware of in their dealings with payors.
Thanks to legislation sponsored by the California Medical Association (CMA), all health plan contracts with physicians are required to be fair, reasonable and consistent with California law and regulations. Contractual clauses that are specifically prohibited cover the following:
- Claims filing deadlines that are inconsistent with the law (see "Unfair Payment Practice: Timely Filing Denials")
- Financial incentives to deny, reduce, limit or delay care
- Gag clauses
- Hold harmless/exculpatory clauses
- Clauses imposing undue financial risk
- Clauses allowing for unilateral amendments by health plans (see "Contract Amendments: An Action Guide for Physicians," and CMA On-Call document #7057, "Managed Care Contractual Protections")
- Clauses requiring physicians to comply with undisclosed quality improvement or utilization management programs (See CMA On-Call document #7001, "Disclosure by Managed Care Plans (and Their Contracting Medical Groups/IPAs")
- Clauses requiring submission of medical records that are not reasonably relevant for the adjudication of the claim (see "Unfair Payment Practice: Unreasonable Requests for Medical Records" and CMA On-Call document #4202, "Health Plan Access to Medical Records.")
Physicians who believe their contracts violate any of these laws are urged to contact CMA's Center for Economic Services (CES) at (888) 501-4911 or firstname.lastname@example.org.
CMA managed care contracting resources
Payor contract negotiations can be difficult. The California Medical Association (CMA) offers a number of free resources and services to help members and their staff simplify the contract review, negotiation and renegotiation process.
Contracting education and coaching:
CES provides one-on-one education and coaching on confusing or problematic managed care contracting issues. Contact CMA's reimbursement help line at (888) 401-5911 or email@example.com.
- "Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors": This toolkit provides physicians and their office staff with practical tips and tools to assist with the negotiation, implementation and ongoing management of complex managed care contracts. The toolkit includes sample forms and letters that may be customized for each medical practice.
- "Contract Renegotiations: Making Your Business Case": When submitting a request to open up a contract renegotiation discussion, best practice is to present a “business case” as to why the payor wants to keep your practice in the network. This resource will help physicians present a thoughtful renegotiation request meant to avoid the quick “auto-reply” from the payor indicating that they are not in a position to renegotiate at this time.
- Health plan contract analyses: CMA provides objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification.
- "Contract Amendments: An Action Guide for Physicians": This guide is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy or procedure.
- Financial Impact Worksheet: It is important that physicians understand how a fee schedule can affect their practice's bottom line so they can make informed decisions about health plan participation before contracts are signed. CMA has developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on their practices based on commonly billed CPT codes.
- Payor profiles: CMA's payor profiles include information for each of the major payors in California, including important contact numbers, addresses, and links for quick reference for payor interactions.
- "Best Practices: A guide for improving the efficiency and quality of your practice": This toolkit offers a series of proven steps that solo and small group practices can take to improve many facets of their practice. Chapter IX, "Surviving Out of Network: One Physician's Experience," offers practical advice, including tips on developing an out-of-network strategic plan.
CMA's health law library, CMA On-Call, includes several documents that address managed care contracting, including but not limited to:
- #7057, "Managed Care Contractual Protections"
- #7051, "Contract Termination by Physicians and Continuity of Care Provisions"
- #7053, "Termination/Exclusion: Action Plan for Physicians"
- #7055, "Exclusivity Provisions and Membership Requirements in Contracts, Including Most-Favored-Nation Clauses"
- #7001, "Disclosure by Managed Care Plans (and Their Contracting Medical Groups/IPAs)"
Contract analysis service
CMA-contracted attorneys provide written reviews of physician contracts for physician members. Contracts are reviewed for compliance with California and federal law and to determine whether, from a business and practical perspective, the provisions of the contract are beneficial for the physician or group. CMA members receive a 20 percent discount on the attorney fees when using one of CMA's contracted attorneys. For more information on CMA's contract analysis service, see On-Call document #7076, "CMA Contract Analysis Service."
Tip: Physicians do not have to accept substandard health plan contracts. You can and should negotiate your contracts.
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® modifier 79 Unrelated procedure or service by the same physician or other qualified health care professional during the postoperative period applies when the same provider (or a provider of the same specialty within a group of physicians billing under the same identification number) performs an unrelated surgical procedure during the postoperative period of another procedure.
CPT® Appendix A (Modifiers) specifies, “The individual may need to indicate that the performance of a procedure or service during the postoperative period was unrelated to the original procedure. The circumstance may be reported by using modifier 79. (For repeat procedures on the same day, see modifier 76).”
For example, explains CPT Assistant, “Modifier 79 is appended to report … a colposcopy performed during the global period of a mastectomy by the same surgeon. (Note that modifier 79 should not be reported with procedures that are related to the original procedure…”
Proper application of modifier 79 directly affects reimbursement. Modifier 79 tells the payor two things:
- The procedure performed during the global period is unrelated, distinct, and separately payable. Payors should not “bundle” or otherwise include the procedure as part of the previous procedure’s global period, nor should they reduce payment for services properly reported using modifier 79
- A new postoperative period should begin when the unrelated procedure is billed.
To further illustrate proper use, CPT Assistant (Sept. 2010) provides a second example:
A 68-year-old woman had an unfortunate landing while bicycling and sustained a mildly non-displaced closed fracture of the right distal ulna. Because of the patient's condition and the nature of the injury, closed manipulation treatment was performed in the operating emergency room, with placement of a long-arm plaster splint. The patient was discharged. Later in the day, the patient returned to the emergency department after experiencing nasal bleeding with clots. After unsuccessful pressure packing insertion and the use of local vasoconstrictors, the patient was returned to the operating room, where bleeding was controlled by repair of a posterior arterial hemorrhage with cautery.
The proper coding is 25535 Closed treatment of ulnar shaft fracture; with manipulation and 30905 Control nasal hemorrhage, posterior, with posterior nasal packs and/or cautery, any method; initial with modifier 79 appended. As CPT Assistant explains, “In this case, the medical documentation reflected that the postprocedural bleeding was not attributable to the initial operation.”
As seen in this example, the physician will perform a separate evaluation and management (E/M) service for the new problem before returning to the patient to the operating room. You may report this E/M service by appending modifier 24 (Unrelated E/M service by the same physician during a postoperative period) to the appropriate E/M service code.
Diagnoses must support separate nature of subsequent procedure
Application of modifier 79 is fairly straightforward; however, “the issues surrounding its use occur when providers and carriers disagree as to whether the procedure is actually ‘unrelated’ to the original procedure,” warns CPT Assistant (Sept. 2003). For example, the unrelated nature of the two procedures may be supported by distinct, separate diagnosis establishing medical necessity for each procedure.
Turn to 78 for related post-op procedures
If the subsequent procedure is related to the underlying condition that prompted the initial procedure, or performed to treat a complication of the initial procedure, modifier 78 likely is appropriate.
Like modifier 79, modifier 78 Return to the operating room for a related procedure during the postoperative period describes a return to the OR during the global period of another procedure, but modifier 78 indicates the subsequent procedure is related to the initial surgery (i.e., it is prompted by a complication or result of the initial surgery). When you append modifier 78 to a claim, the global period does not reset, and the payor may reduce payment to reimburse only for the “intra-operative” portion of the service.
MEDICARE: Physicians who receive Medicare revalidation notices that require submission of a completed application will have their enrollment records placed in a pend status if they do not submit the application by the deadline specified in their revalidation notice. For example, physicians who missed the most recent September 30 deadline will have their enrollment pended beginning October 10-14, 2016. The pend status holds all paper checks, Standard Remittance Advices and Electronic Funds Transfers from being issued until a revalidation application is received. Practices that missed their deadline should submit and sign the application online through the PECOS system as soon as possible to prevent deactivation and possible forfeiture of payment. If you have questions about the revalidation process, click here or contact Noridian at (855) 609-9960.
WORKERS’ COMPENSATION: The Division of Workers’ Compensation (DWC) has added a search tool on its website to help find Independent Bill Review (IBR) determinations quickly and efficiently. The new tool allows IBR determinations to be located by decision on date of application receipt and decision issuance, case decision and applicable fee schedule. More information about the IBR process can be found on the DWC website.
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.
10/19: Assembly Bill 72: Out-of-Network Billing: How it Works, Who it Impacts and How to Avoid it: In September, Governor Jerry Brown signed a controversial bill, Assembly Bill 72, into law. This bill will change the billing practices of non-participating physicians providing non-emergent care in in-network hospitals, ambulatory surgery centers and laboratories. This webinar will present an overview of the new law, providing members with the information to understand the circumstances under which the bill applies, how physicians can continue to charge their usual rate, and the opportunity to improve network adequacy standards. (Members only)
11/2: Is Your Practice at Risk for a HIPAA Security Breach? Medical practices are at increasing risk for HIPAA security breaches such as ransomware, or theft of electronic patient information. Increased dependency on electronic health records and exchange of data with other providers, or staff turnover can compromise security. In this webinar, CMA’s HIPAA advisor, David Ginsberg, will discuss common threats and breaches, how to safeguard and strengthen your systems, and what to do if you have a breach.
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.