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DHCS Continues Fixes to Computer Systems for ACA Primary Care Rate Increases

DHCS Continues Fixes to Computer Systems for ACA Primary Care Rate Increases
By the California Medical Association

As of April 11, 2014, the Department of Health Care Services (DHCS) updated its computer systems to process individual fee-for-service (FFS) claims at the new higher rates under the Affordable Care Act (ACA) primary care provider rate increase. With that update DHCS also released local code crosswalks for evaluation and management (E/M) and vaccine administration codes. There were, however, a few remaining exceptions for some specialized claims that were being paid at the lower rate as DHCS continued to update its systems to handle those claims.

The June 17, 2014, Medi-Cal provider bulletin announced the latest options for processing retrospective NICU/PICU claims from part of the local code crosswalk at the higher rates. While the standard appeals process is to submit a Claim Inquiry Form (CIF), after feedback from the California Medical Association (CMA) and other stakeholders, DHCS agreed to allow claims data to be submitted by upload of a report to the Medi-Cal web site without submitting a CIF form. Practices now have a choice on how to resubmit retrospective NICU/PICU claims back to January 1, 2013, to receive the additional payment due. See the June 17, 2014, Medi-Cal provider bulletin for more details.

The only remaining exception to the initial ACA PCP rate increase funds release is crossover (Medi-Medi) claims. As previously reported, the Centers for Medicare and Medicaid Services (CMS) is requiring DHCS to modify its proposed bundled code methodology for crossover claims, as it would have consistently underpaid physicians anytime they billed a code eligible for the increase with any other codes that are not eligible. Thanks to CMA advocacy, CMS ordered DHCS to change its payment methodology to ensure that California physicians get the full benefit of the ACA primary care increase. DHCS’s goal is to update its pricing system in July to correctly pay the crossover claims prospectively.

The next step will be for DHCS to issue a final settlement and a comprehensive “true up” of payment for any and all remaining outstanding funds. The releases will be in gradual steps starting as early as August 2014, and will include claim level detail by patient to allow practices to reconcile the entire amount paid according to the increased funds released.

For Child Health and Disability Prevention (CHDP) providers, CMA was told that some practices were previously instructed to bill at their Medi-Cal rates, causing concern based on DHCS pricing logic of paying the lessor of Medicare’s rate or the billed charges, resulting in some practices not qualifying for the increase. CMA inquired with DHCS how practices that previously billed at the Medi-Cal rate or those whose electronic health records system only allowed them to enter the Medi-Cal rate would qualify for the PCP rate increase. DHCS has proposed a workaround so CHDP physicians can receive the increase, but the submission format has not yet been finalized. Once the CHDP rate increase submission format has been finalized, DHCS will issue another bulletin.

As for the status on the managed care plans' payments, CMA has heard from DHCS that the plans will release the funds by the end of July, however, timing of when physicians will receive the checks is dependent upon whether the plan is distributing the funds directly to physicians or whether they are delegating distribution of funds to the medical group/IPA.

CMA will continue to monitor the timing of distribution of funds from Medi-Cal managed care plans , as the delays have hit a number of practices particularly hard.

There's Still Time to Attest!

According to DHCS, eligible physicians who have already attested have received over $200 million in ACA primary care rate increases. Don't miss out! Remember, to qualify for enhanced payments for fee-for-service Medi-Cal and Medi-Cal managed care plans, you must first self-attest to your eligibility. The deadline to attest, if you haven't already done so, is December 31, 2014. If you have attested and not received your additional funds, practices should confirm the accuracy of the information submitted through the attestation process. Practices with questions can call Medi-Cal’s Telephone Service Center at (800) 541-5555.

For more information on this topic, see CMA's "Medi-Cal Primary Care Physician Rate Increase FAQs," available free to members in CMA's online resource library.


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