Palmetto and Other Problems

The Palmetto is the state tree of South Carolina, known for its large and nutritious leaf bud. The palmetto bug is actually a cockroach, but don’t tell that to the people of Florida who allow them to coexist on their property. Saw palmetto is good for the prostate gland. But to the physicians of San Diego County and the rest of California, Palmetto is now a big problem.

Palmetto GBA is the new Medicare fiscal intermediary taking over this year from NHIC, and many physicians are not getting paid for their services. In large numbers, physicians are turning to SDCMS and CMA for help, and organized medicine is willing and able to help its members. Some physicians have recently joined SDCMS just in order to get help dealing with Palmetto. Membership has its benefits, yet sometimes it takes a crisis to remind physicians they are better off not being alone out there.

Executives of Palmetto GBA recently came to the CMA House of Delegates and apologized for all the problems. They agreed to work hard to fix the problems, and CMA and SDCMS will hold them accountable, and be the source of current information. SDCMS continues to send out its e-newsletter, “News You Can Use” (to SDCMS members only), with the latest information. Members got answers to these 14 key problems:

1. I can’t get through to Palmetto GBA’s call center. When I do get through, I’m on hold for a long time.
2. Palmetto now has a message that allows us to go to voice mail and leave a request for a return call. It says we will get a call back within 24 to 48 hours. It has been two days, and I have not yet received a call.
3. I am trying to get a status of my enrollment application. Who do I call?
4. How do I get the status of my claims?
5. How do I know if checks have been issued, and how much is approved to pay once the payment floors have been reached?
6. I submitted my application to NHIC, and it still has not been completed. I am not getting paid.
7. How long will it take my enrollment application to be completed once I submit it to Palmetto?
8. I still have not received my submitter password. I was previously submitting claims electronically to NHIC, so I am not new.
9. I am a new submitter to EDI. How long will it take for me to get my submitter number and password?
10. All of a sudden my claims are rejecting under message Y1C. Why?
11. How can I find out what issues Palmetto has had with the transition?
12. I haven’t been paid since Palmetto took over.
13. I am getting denial or rejects for services (procedure codes/modifier invalid) that NHIC used to pay. Why?
14. My claims were going through with my NPI and PTAN before transition, and now they are not. Why?

But dealing with Palmetto GBA is only one small reason to be a member of SDCMS and CMA. Any practice management concern is addressed Marisol Gonzalez, your full-time SDCMS physician advocate — Marisol’s job is to help physicians succeed in practice. No expensive consulting fees. You and your staff may call as often as you like, and the service is concierge.

Your San Diego County delegation to the recent CMA House of Delegates (HOD) again demonstrated that we are the best county in California for organized medicine. Led by Encinitas physician Jim Hay, the HOD spent three days addressing every conceivable issue facing medical practice. San Diego County physicians demonstrated reason and calm in face of higher emotions elsewhere. We are the problem solvers and peace makes, while still being innovative with issues such as soccer head protection and membership. We shined by having the highest voluntary participation in CAL-PAC, CMA’s political action committee.

Every year, about 3,000 bills are introduced into the California Legislature. CMA looks at all of them and addresses every one that is health related in great detail. Every year there is a bunch of bills from psychologists, nurses, podiatrists, optometrists, chiropractors, and every other nonphysician provider seeking to expand their scope of practice into practicing medicine. Every year CMA’s lobbying team beats these off. Frequently, these bills have strong personal interest among legislators, who learn the power of CMA.

The centerpiece of California law for physicians is the MICRA protections of liability abuse. We continue to have affordable liability insurance in this expensive and litigious state due to MICRA. CMA is the wall of defense of MICRA, and every year the trial lawyers test its strength. We know the position on MICRA of every state legislator, and if it is not on our side, we help take them out of office whenever possible.

These are just some of the things your dues dollars are doing for you. SDCMS and CMA are a small investment compared with all the savings organized medicine provides to physicians in all practices, small, medium, and large. The discounts on various services alone more than pay for the dues. The work in Sacramento and with Palmetto is extra money in your pocket.

This is December, and if you have not done so already, go to www.SDCMS.org and pay your 2009 dues. We are “Physicians United for a Healthy San Diego.”

SDCMS Palmetto Success Stories

SUCCESS STORY #1: Right after the transition from NHIC to Palmetto, one of our member hematology oncology groups began to have “delay of payment” reimbursement issues with Palmetto. This delay of payment had a severe impact on their practice, and they were worried that they were going to be forced to admit patients to a hospital for treatment as it became increasingly cost-prohibitive to provide the care they needed in their office.

SDCMS and CMA were able to review the check amounts with Palmetto, including those claims that were to be released after the 14-day payment floor (CMS mandatory hold). We were able to get this practice’s claims released for payment, as well as provide them with the status of their “pending amounts” (claims that need to be manually processed and are within the required payment period).

SUCCESS STORY #2: A solo member physician was having difficulty getting his enrollment application through Palmetto’s system. He had submitted his application long before the intermediary transition. His billing company wasn’t able to begin billing for him due to this problem. After several unsuccessful attempts to get a status on his application with Palmetto’s provider enrollment, he called SDCMS for assistance.

SDCMS and CMA were able to get his enrollment application expedited through Palmetto’s system. The billing company is now successfully billing claims for this physician.