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Ask Your SDCMS Physician Advocate

Have a Practice Management or Membership Question?

SDCMS members and their office managers / practice administrators can contact your physician advocate, Marisol Gonzalez, for assistance at (858) 300-2783 or at MGonzalez@SDCMS.org.




SDCMS Member Physician Question: My physician is inquiring about a mandatory program he must enroll in for opiate prescriptions. Do you know anything about this?

Marisol's Response: Under California law, 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) must register to use the Controlled Substance Utilization Review and Evaluation System (CURES) by July 1, 2016.

 CMA has compiled a list of educational materials that serve to familiarize physicians with the registration process and key features of the newly upgraded system, CURES 2.0. Additionally, CMA will be co-hosting a live webinar about CURES 2.0 with the Department of Justice on March 16, 2016 — click here.

SDCMS Member Physician Question: A local physician has recently retired, and all of her former patients are coming to me for care. I have requested copies of medical records from this physician, but she wants to charge me for producing these copies. Is this legal?

Marisol's Response: As a matter of professional courtesy, most physicians do not charge fees for transferring records directly to another physician. The law, however, does not govern whether a physician can charge to transfer copies of medical records to another provider, so there is nothing to preclude a physician from charging a copying or transfer fee, nor is there any requirement to transfer records within a certain time period or at all. For more information, SDCMS-CMA members can access CMA ON-CALL document #4000, "Medical Records Most Commonly Asked Questions."

SDCMS Member Physician Question: I am updating the job descriptions for my staff, and I want to make sure I’m paying them adequately to correspond with their new duties. Do you have salary information available for the staff of a medical office?

Marisol's Answer: Yes. SDCMS conducts biennial surveys of medical staff salaries in San Diego County, with results inclusive of both clinical and administrative staff and broken down by the various areas in the county. If you are interested in obtaining our 2015 survey report, please email me at MGonzalez@SDCMS.org.

SDCMS Member Physician Question: I was told by one of my colleagues that I would have to enroll in the Medi-Cal program because I order, refer, and prescribe for Medi-Cal patients. I do not currently participate in the Medi-Cal program. If I enroll, will I begin to get reimbursed by the Medi-Cal program?

Marisol's Response: No. This special type of enrollment is for the sole purpose of ordering, referring, or prescribing items or services to Medi-Cal beneficiaries. This type of enrollment does not allow the Medi-Cal program to reimburse you. The required application for this type of enrollment is Medi-Cal Ordering / Referring / Prescribing Provider Application / Agreement / Disclosure Statement for Physician and Non-Physician Practitioners (DHCS 6219).

SDCMS Member Physician Question: I’m having a hard time registering for CURES online. I think I may already be registered as it’s giving me an error stating that my name is already in the database, but I don’t remember registering. What can I do?

Marisol's Response: You can contact the CURES Help Desk at (916) 227-3843, 8:00am–5:00pm, Monday through Friday. The Department of Justice has added phone lines and support staff to make sure users gain quicker access to assistance when needed.

SDCMS Member Physician Question: As an endocrinologist, do I need to have 12 hours of CME on pain management and the appropriate care and treatment of the terminally ill?

Marisol's Response: Yes. Only pathologists and radiologists are exempted from this requirement. The 12 units may be divided in any way that is relevant to your specialty and practice setting. Physicians must complete the mandated hours by their second license renewal date or within four years, whichever comes first. For more information on CMEs, click here.

SDCMS Member Physician Question: I’ve received a subpoena for copies of medical records from another state. In the subpoena, it asks for the copies to be notarized. Can I pass this cost along to the requestor?

Marisol's Response: Yes, this cost can be included in your clerical costs incurred in making the records available, which includes special processing. CMA’s ON-CALL document, "Subpoenas: Guide for Responding," addresses these costs in more detail.

SDCMS Member Physician Question: I have prior authorizations for patients I will see in October. These prior authorizations have ICD-9 codes on them. Will these still be valid after October 1?

Marisol's Response: The California Medical Association (CMA) asked some of the major payors what their policies would be regarding prior authorizations approved using ICD-9 codes. Some of these payors will be honoring these prior authorizations for services performed after October 1. CMA believes prior authorization laws would protect physicians unless the service provided is completely different from what was authorized.

For more information on what physicians need to know about the ICD-10 transition, SDCMS-CMA members can click here to access CMA’s ICD-10 Transition Guide.

SDCMS Member Physician Question: I understand for a one-year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes. Will Medi-Cal and the private payors follow Medicare’s lead?

Marisol's Response: So far, it doesn’t look like Medi-Cal will be following Medicare’s lead. CMA has inquired with some of the major payors as well, and they will be sticking to their guns on full specificity being required, etc. Should any of this change, we will communicate this to our members.

SDCMS Member Physician Question: We’ve recently had a patient refuse to provide us with photo identification as they stated this was an invasion of privacy. Is it illegal to request photo identification from patients at the time of service?

Marisol’s Response: No, it is not illegal. According to CMA’s ON-CALL document #7604, “Red Flags Rule,” “To the extent feasible and reasonable, prior to registering anyone as a new patient, office personnel shall request to see a government-issued photo identification and documentation of the person’s name, current residential address, and insurance coverage information. No person shall be registered as a new patient unless his or her identity has been verified.”

SDCMS Member Physician Question: How will we know if we’ve failed to meet the Physician Quality Reporting System (PQRS) reporting requirements for the previous year? Are there any reports we can access to review the data submitted?

Marisol's Response: The Centers for Medicare and Medicaid Services (CMS) reviews feedback reports in the August / September timeframe to review all PQRS activity for the previous year. They are reviewing these reports to determine if eligible professionals (EP) have successfully reported on all measures. During the months of October, November, and December, CMS sends notices to EPs who have not successfully reported on all of the measures. These feedback reports are made available for EPs to review.

SDCMS Member Physician Question: I have Medicare / Medi-Cal patients who are upset because they were passively enrolled into a health plan where they will no longer be able to see me for care. These patients don’t understand the Cal MediConnect program and want to be able to discuss their options with someone. Who can they contact for this information?

Marisol's Response: If your patients would like to obtain free, individual counseling to assist them in deciding which Medicare and Medi-Cal option best meets their needs, they can contact Health Insurance Counseling and Advocacy Program (HICAP) at (858) 565-8772. After your patients decide on a plan, they will need to enroll in, change, or leave a health plan — they can contact Health Care Options at (844) 580-7272. If your patients have complaints or a problem with the Cal MediConnect program that they have not been able to get resolved to their satisfaction, they can contact Cal MediConnect Ombudsman at (855) 501-3077.

SDCMS Member Physician Question: I will be leaving the practice where I am currently employed. The medical group will be taking over all of my patients when I leave. Will I need to communicate this to my patients, even though they will continue to be cared for?

Marisol's Answer: To protect patients and reduce the risk of liability, physicians should notify patients sufficiently in advance of retiring, leaving a medical group, or closing their practice. This will afford patients a reasonable opportunity to find another physician. Where the practice is to be taken over by another physician or the physician’s own medical group, and/or another physician can be recommended, the patients may be referred to that physician.

SDCMS Member Physician Question: I’ve finally been through the credentialing process to become a contracted TRICARE provider. Reading through the participation agreement, I noticed that I cannot be opted out of the Medicare fee-for-service program while participating in TRICARE. Is this true?


Marisol's Response: Yes. According to the TRICARE Provider Handbook, “A provider must participate in Medicare (accept assignment) and submit claims on behalf of all TRICARE and Medicare beneficiaries.”

SDCMS Member Physician Question: I am looking for an ICD-10 workshop to help me prepare for the ICD-10 switch on October 1, 2015. Will SDCMS be running any courses?

Marisol's Response: Yes. The American Academy of Professional Coders (AAPC) will be running a two-day workshop on June 25 and 26 at SDCMS's offices. It will be $399 for SDCMS members, and your staff is welcome to attend at the same price. Nonmembers may attend at $599.

This training will focus on:

  • ICD-10 Format and Structure
  • Complete, In-depth ICD-10 Guidelines
  • Nuances Found in the New Coding System With Coding Tips

Here’s what’s included:

  • 16 CEUs
  • AAPC ICD-10-CM Code Set Course Manual
  • AAPC ICD-10-CM Code Set Draft Book
  • AAPC Online ICD-10-CM Proficiency
  • Assessment (Required for Current AAPC CPCs to Maintain Their Credential)
  • Access to AAPC’s Online ICD-10-CM Assessment Training Course through December 31, 2015

Space is limited. You can register by calling (800) 786-4262 or by visiting www.cmanet.org/AAPC-ICD10.

Questions? Contact Juli Reavis at (916) 551-2046 or at jreavis@cmanet.org.

SDCMS Member Physician Question: We’ve had several missed appointments at our office over the past few weeks. These patients have had these appointments for months, and they don’t call in to reschedule or notify us that they will not be coming in. Can we charge patients for missed appointments?

Marisol's Response: Private Payors: Unless a physician has entered into a contract with a payor that prohibits these charges, a physician may charge a patient when he or she misses an appointment or does not cancel in sufficient time to allow another patient to fill the appointment slot, if advance notice of such procedure is given.

Workers’ Compensation: In workers’ compensation, physicians may bill payors for missed appointments for treatment (use code 99049) and for med-legal services (use code ML 100). However, these codes do not guarantee payment. While the physician must explain why payment should be made, e.g., no portion of the patient’s requested appointment slot was filled that day, it is up to the claims administrator to decide whether to pay for the missed appointment.

Medicare and Medi-Cal: Neither the Medi-Cal nor Medicare program provides any benefit for missed appointments.

SDCMS Member Physician Question: We received an overpayment request from TRICARE for a patient we saw over three years ago. How far back can TRICARE go for these requests? Can I fight this?

Marisol's Response: Pursuant to federal law, TRICARE is authorized to seek refunds of overpayment on dates of service as far back as 10 years. In your case, this overpayment request is as a result of eligibility. You can submit a Good Faith Payment request if you are unable to get a hold of the beneficiary. Here is what is needed for submitting Good Faith Payment:

  • Proof of eligibility at time of service-example-copy of ID card
  • Proof of reasonable efforts to collect payment from beneficiary
  • Copy of recoupment letter or Refund Control Number (RCN)

SDCMS Member Physician Question: I received a fax from a company called Inovalon, requesting medical charts for two of our Anthem Blue Cross patients. Is this a legitimate request?

Marisol's Response: Yes. In July 2014, Anthem Blue Cross began chart reviews on enrollees who purchased an individual exchange or mirror product. Similar to the Medicare Risk Adjustment Audit process, and as required by the Affordable Care Act (ACA), the audit is designed to identify the health status and demographic characteristics of exchange / mirror product enrollees.

Blue Cross will review diagnosis code data obtained from the medical records of exchange patients. This is not a typical audit on the physician practice; rather, Blue Cross is looking to identify conditions / illnesses that demonstrate patients who are at risk for being sicker or patients who are predicted to be healthier. This information will be utilized to report to the Centers for Medicare and Medicaid Services the health status of exchange plan enrollees. Blue Cross reports it will also utilize the data to better manage patient health conditions.

SDCMS Member Physician Question: One of my colleagues told me that there is a new law or procedure when prescribing opiates. I believe it has something to do with having a patient fill out a questionnaire. Is this true?

Marisol's Response: The Medical Board of California (MBC) did create new guidelines for prescribing controlled substances for pain in November of 2014. They created a suggested treatment agreement to be used to structure a plan to work with your patients to treat their chronic pain. The intent of this agreement is to protect your patient’s access to controlled substances, and your ability to prescribe them. Click here for the new guidelines created by the MBC. In addition to the agreement created by the MBC, a group of stakeholders in San Diego County, led by Dr. Roneet Lev, created a patient pain medication agreement and consent form. This agreement takes the extra step of making sure your patients understand their responsibilities with these medications, which have a high potential for abuse — click here to access the document.

SDCMS Member Physician Question: I received a letter from CMS informing me of a 1.5% cut in my Medicare reimbursements for 2015. I am a solo practitioner who does inpatient consultation and have no office. I don’t have an EHR, so I can’t see how the reporting applies. How can I get this reviewed and reversed? 

Marisol's Response: Medicare participating physicians who failed to meet reporting requirements of the Physician Quality Reporting System (PQRS) from January 1, 2013, through December 31, 2013, will begin to be penalized by a 1.5% reduction in their reimbursement rate beginning in 2015. If you are a physician who bills for Medicare Part B services, you have the ability to participate in the PQRS program.

If you have a received a letter from CMS notifying you of this reduction, and you would like to request an informal review, you can do so here

After clicking on the link, you will head to the left side of the page under “Related Links” and expand the “Communication Support Page” option. You will see “Informal Review Request,” click on this and follow the instructions to submit the request. It will take CMS 90 days to process this review.

PLEASE NOTE: Submitting an informal process may not get your 1.5% cut reversed. Again, if you are a physician who bills for Medicare Part B services, you do have the ability to participate in the PQRS program. Reductions in your Medicare reimbursement will increase to 2.0% beginning in 2016 if you continue to choose not to participate in the program.

SDCMS Member Physician Question: I was told that beginning January 2015, Medicare would start paying physicians a monthly fee to coordinate the care of beneficiaries with chronic illnesses. Is this true? What information is available to begin billing for this?

Marisol's Response: Yes, effective January 1, 2015, Medicare was to begin paying for chronic care management (CCM) services. The Centers for Medicare and Medicaid Services (CMS) created CPT code 99490 to bill for these services. These are for patients with chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation / decompensation, or functional decline. CMS expects that physicians will particularly focus on eligible patients with higher acuity and higher risk (e.g., patients with four or more chronic conditions) when furnishing CCM services because the benefits are likely to be greater. Currently, the only information available about the specifics of this code is available on the federal registry. Once we get more specifics, we will get the information out to SDCMS members.

SDCMS Member Physician Question: One of our patients is recommending that their friend come to us for care. This friend has Covered California through Sharp HMO. We are not contracted with this plan. Are we OK to bill the patient directly?

Marisol's Response: Yes. If you are not contracted with this plan, you are within your rights to bill the patient directly. It is strongly recommended that you make sure the patient understands that they will be responsible for payment of services. You want to make sure that the patient signs a financial responsibility form as well so this understanding is in writing.

SDCMS Member Physician Question: I am looking into medical record retention periods for our practice. I am specifically looking for the retention periods for cytology and skin tissue slides. Where can I find this information?

Marisol's Response: According to CMA ON-CALL document #5300, "Business and Professions Code," §§1271 and 1274 require that medical records, cytology slides, and cell blocks be retained by licensed clinical laboratories for a minimum of five years, and cytology reports (including a report correcting errors in a previous report) for a minimum of 10 years. For more information, SDCMS members may contact Marisol Gonzalez, your SDCMS physician advocate, at (858) 300-2783 or at MGonzalez@SDCMS.or.

SDCMS Member Physician Question: We’ve sat in on a couple of seminars you’ve run recently, and we would like to obtain any recordings available for training purposes for a couple of new employees at our office. Do you record these educational sessions? If so, how can I obtain them?

Marisol's Response: Yes. Every seminar we run here at SDCMS is recorded and posted onto our website for on-demand viewing. With the presenter's approval, seminars and webinars are always recorded and accessible to SDCMS members and their staff. To access recordings, click here and log in. SDCMS members and staff can always contact me to obtain these recordings as well. I can be reached at MGonzalez@SDCMS.org or at (858) 300-2783.

SDCMS Member Physician Question: There are a couple of small payors reimbursing us for our services using credit cards. Our office has to run these credit cards in separate transactions, and we end up incurring the cost of these credit card fees. What can we do?

Marisol's Response: When paying claims, some payors have shifted from paper checks to electronic payment methods, including payor-issued virtual credit card (VCC) payments. With this method, a payor sends credit card payment information and instructions to physicians, who process the payments using standard credit card technology.

The method is beneficial to payors but costly for your practice. Health plans often receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are born by the physician practice and can run as high as 5% per transaction.

Here are three routes physicians can take to minimize such fees:

1. Register for Electronic Funds Transfer (EFT) Payments: The Health Insurance Portability and Accountability Act (HIPAA) requires all health plans to offer standardized EFT using the Automated Clearinghouse (ACH) Network. Similar to direct deposit, ACH EFT allows health plan payments to be directly paid into a physician’s designated bank account. Each ACH EFT transaction carries only one fee of about $0.34, far less than the potential 5% fee charged to VCC transactions. In order to receive ACH EFT, physicians should request and register for this payment method with payors.

2. Be Aware of Restrictions in Payment Methods When Contracting With Health Plans: Even though HIPAA requires health plans to make EFT payments available upon request, health plans may try to require other payment methods, such as VCC, within their contracts with physicians. Be cognizant of any such restrictions and avoid signing contracts with inflexible payment terms.

3. Educate Your Practice Staff: If your practice staff processes both patient and health plan payments, make sure they know how to differentiate between patient and health plan credit card payments to avoid authorization of VCC payments from health plans.

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