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“News You Can Use” — April 19, 2013



Watch a 10-minute Video Update on Federal, State, and Local Issues by SDCMS President, Dr. Sherry Franklin, and SDCMS CEO, Tom Gehring: Click here if you’re at a computer. Click here if you’re on a smartphone or tablet.

Executive Director Comment:: We need your help in identifying the scope of the problem with the TRICARE transition. Please take the survey directly below so that we can go after the mismanagers of the transition!

If You Haven’t Already Done So, Please Take CMA’s TRICARE Transition Survey Now — It’ll Take Less Than 60 Seconds! Click Here

Executive Director Comment: We are now seeing more, but not all, details on the so-called Medi-Medi transition. Here are the highlights!

Medicare / Medi-Cal Dual-Eligibles Highlights:

  • Background: On March 27, CMS gave approval to require California Medicare / Medi-Cal dual-eligibles to enroll in a managed care plan -- called CalMediConnect, affecting 450,000 dual-eligibles in eight counties, including San Diego -- on October 1, 2013 using the following Medi-Cal managed care plans: Care 1st, Community Health Group, Health Net, and Molina.
  • Enrollment Process and Opt Out: Dual eligibles will begin receiving notices regarding the CalMediConnect program in July 2013, 90 days before enrollment, with subsequent notices in August and September. Patients who do not select a health plan after all three notices will be “passively enrolled” into a plan selected by DHCS. Patients will have the ability to opt out of the demonstration into fee-for-service Medicare at any time.
  • Physician Rates and Payment Rules are not yet clear as it will be left to the plans to negotiate with their provider networks. Once patients are enrolled in a plan, they can continue to see a physician with whom they have an existing relationship — even if the physician is not contracted with the plan — for up to six months for Medicare and up to 12 months for Medi-Cal services. Physicians will be paid at the Medicare fee schedule rate for those services. In an urgent or emergent situation, the plans will be required to pay out-of-network physicians at the Medicare fee-for-service rate for Medicare services, and the Medi-Cal fee schedule for Medi-Cal services.
  • Delivery System: CalMediConnect plans will be required to cover all services currently covered by Medicare Parts A, B, or D (physicians, hospitals, and prescription drugs, respectively), and any services currently covered by Medi-Cal, including services in state waivers. In addition, plans will be required to cover some services that are currently not covered by either Medicare or Medi-Cal, including vision, dental, and medical transportation.
  • Network Adequacy: For Medicare services, health plans will be required to meet Medicare Advantage standards for network adequacy, unless the Medi-Cal standards are more stringent. Networks will be subject to an initial assessment and ongoing monitoring by the Department of Managed Health Care. Plans will be required to ensure that their providers comply with all requirements of the Americans with Disabilities Act. Although it is not specified in the MOU, this could entail plans performing a facility site review (FSR) similar to what was done for the enrollment of seniors and persons with disabilities into managed care.
  • Next Steps: The MOU left many questions unanswered, including important details about the opt-out form and process.
    Click here to access the full memo from CMA.


Avian Influenza A (H7N9) Virus Update: On April 1, 2013, WHO first reported 3 human infections with a new influenza A (H7N9) virus in China. Since then, additional cases have been reported. Most reported cases have severe respiratory illness and, in some cases, have died. At this time, no cases of H7N9 have been reported outside of China. The new H7N9 virus has not been detected in people or birds in the United States.

Physician Lifestyle Report 2013: Does Burnout Affect Lifestyle? Click Here

April Is Donate Life Month: Visit the Donate Life California website for further information on how to inspire people to sign up with the state organ and tissue donor registry. Click here for a special SDCMS link.


Medicare Enrollment Referring / Ordering Deadline: Medicare is preparing to go live on May 1 with the referring / ordering edits that will result in claims denials unless the referring / ordering physician or other healthcare provider is enrolled in Medicare (or has a valid opt-out affidavit on file with their local Medicare contractor). To be clear, it is the billing provider’s claim that is at risk of being denied. AMA was instrumental in securing a delay in the implementation of this policy (which was originally scheduled to go into effect in 2010) so that physicians had sufficient time to enroll (or file a valid opt-out affidavit). AMA, together with MGMA, have prepared a fact sheet (click here), which you may find helpful. For more information on Medicare enrollment, click here ...

Blue Shield Follows Blue Cross’s Lead to Require Physicians to Notify Patients Before Referring Out-of-network: Effective May 15, physicians will be required to notify patients in writing using a form provided by the payor when referring a patient to an out-of-network provider. The policy does not apply to emergencies. Click Here

Medi-Cal Extends 2012 EHR Attestation Deadline to April 30 Click Here

Have You Checked Your MBC Profile Lately? California law requires you report each and every address change within 30 days. Click Here


Problem Impacting Claims Received by Palmetto GBA on or After April 1, 2013: The issues affect (1) all claims for assistant-at-surgery services, and (2) all Ambulatory Surgical Center claims. As a result of the system issues, CMS has instructed Medicare contractors to hold these types of claims until April 14, 2013, when system fixes are expected to be implemented. Physicians should see minimal impact on the timeliness of these claims and their cash flow, as current law requires electronic claims to be held 14 calendar days, and paper claims for 29 days after the date of receipt.

ACA High-risk Pool Failings Offered as Cautionary Tale Click Here


UCSD Free Clinic Seeking Volunteer / Internship Opportunities for Bridge to Employment Program Click Here

University of San Diego Needs NP Student Preceptors: USD is currently securing preceptors for summer semester (June 3 - August 23). If you would like more information about educating an NP student or if would like to volunteer, please contact rdevere@sandiego.edu or (619) 260-4718.


CMA Practice Resources (April 2013) Highlights:

  • Blue Cross corrects two problems affecting accurate payment of new psychiatric codes — Click Here
  • Medicare to implement ordering / referring physician edits — Click Here
  • Feds approve California’s dual-eligible pilot project — Click Here
  • Act now to avoid Medicare penalties in 2015 — Click Here
  • Next phases of Healthy Families to Medi-Cal transition scheduled for April 1 — Click Here
  • The Coding Corner: The Ins and Outs of New vs. Established — Click Here
  • Federal court to decide Medicare MAC contract protest — Click Here

CMA Regulations Quick List (Updated March 25, 2013) Click Here

Follow SDCMS’ Twitter Feed and Get a Treasure Trove of Healthcare News Delivered Daily Right to Your SmartphoneClick Here

Obtain EHR Meaningful Use Incentive Payments: The SDCMS Foundation is proud to announce programs to help independent primary care providers in practices of 1-20 providers obtain EHR meaningful use incentive payments. Practices must meet specific eligibility requirements, and the services will be provided until the project funds are exhausted. For more information, contact Victor Bloomberg, LCSW, IT Project Manager at the SDCMS Foundation, at Victor.Bloomberg@SDCMS.org. Sponsored by the San Diego Beacon Collaborative and CalHIPSO.

Is Your Office Manager / Practice Administrator Using SDCMS’ Online Forum? Click Here to Join

“The only difference between death and taxes is that death doesn’t get worse every time Congress meets.”
— Will Rogers (1879–1935)

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