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SDCMS "News You Can Use" (2010.06.23)

by: San Diego County Medical Society
Published June 24, 2010

SDCMS "News You Can Use"
— June 23, 2010

SO WHAT'S UP WITH SGR?

  • IN CONGRESS: House Speaker Nancy Pelosi has said that her chamber will not pass the stand-alone Medicare SGR bill approved by the Senate on Friday, June 18, 2010. Pelosi called the Senate measure "inadequate" because it only stops the Medicare cuts for six months and doesn't address other parts of the jobs bill passed by the House on May 29, 2010. The House-passed measure - HR 4213, the "American Jobs and Closing Tax Loopholes Act of 2010" - would stop the Medicare cuts for 19 months, would give physicians a 2.2% payment update for the remainder of this year, and would give physicians a 1% payment update for 2011. The bill also included the California geographic payment (GPCI) fix, which provides $400 million so that currently underpaid counties will be reimbursed based on more accurate geographic practice costs. Senate Democratic leaders have repeatedly trimmed their version of the bill in an attempt to attract Republican votes. In a last-ditch effort on Friday (June 18), they decided to pass a stand-alone SGR bill that would delay the cuts only until December 2010. House and Senate leaders are currently negotiating a pared-down version of HR 4213 to garner the necessary 60 votes in the Senate. The most significant change being discussed is reducing the $24.2 billion provision that extends extra federal Medicaid matching (FMAP) funds to cash-strapped states like California. The scaled-back bill would still include the House-passed Medicare SGR provision and the California GPCI fix. House and Senate leaders have said that they hope to resolve this issue by Thursday night, June 24. Once the Senate passes the scaled-down version of HR 4213, the House will promptly vote as well.
  • AT PALMETTO / CMS: Physician claims submitted for services provided in June are being processed under the reduced payment rate on a rolling, first-in/first-out basis - claims submitted earliest are now being paid at the reduced rate, while newer claims will continue to be held for a 10-day period until the president is able to sign legislation into law. We anticipate that whatever legislation is passed will apply retroactively to all services provided since June 1, 2010, and that claims that have already been processed will be adjusted automatically without physicians having to resubmit them. Palmetto will do a "rolling hold" on new claims so that they will not be priced immediately upon receipt. Generally, claims are priced as they come in and then held for 14 days before they are released for payment. A "rolling hold" means that claims would not be priced until after they sit on the payment floor for 14 days. Claims with dates of service prior to June 1, 2010, will not be affected.
  • IN YOUR EXAM ROOM - Patients Cannot "Just Pay the Difference" Between the Old and New Reimbursement Rates: After some physicians notified patients that they would not be able to see them until this matter is resolved, some of the patients wanted to keep their appointments as scheduled and asked if they could "just pay the difference" for the 21% reduction. Medicare rules do not allow patients to do this.

UPDATED PHYSICIANS GUIDE TO CAL-NET PHYSICIANS IPA CLOSURE
Cal-Net Physicians IPA serves approximately 5,489 enrollees in San Diego County. Cal-Net contracts with Molina Health Plan, Community Health Group, and Care 1st to provide services to Medi-Cal and Healthy Families enrollees. CMA has learned that these health plans have terminated their contract with Cal-Net, effective June 1, 2010, due to financial solvency concerns. Click here for details on health plan transition plans, the names of the receiving medical groups/IPAs, continuity of care information, and other important information for physician practices.

CONTENTS

  • Blue Cross Will Not Pay for Post-surgical Complications
  • DHCS Announces Fee-for-Service Provider Payment Delay
  • New CMA ON-CALL Document #1250, "Ten Strategies to Protect Quality Through Medical Staff Self-governance"
  • Blue Cross Announces Changes to Prudent Buyer Contract
  • Update on SB 726 - a Bill That Would Erode the Corporate Practice of Medicine Ban
  • Federal Medi-Cal Audits to Begin in August
  • State Auditor Finds That Medi-Cal TAR Process Should Be Streamlined
  • Appeal, Appeal, Appeal
  • Ask the Expert: "Payment in Full"
  • Clarifying the Distinction Between "Private Contracting" and "Balance Billing"
  • Reminder: PECOS Enrollment Deadline Is July 6, 2010
  • Questions Regarding E-prescribe Bonuses
  • American Red Cross Extends Deadline for Real Heroes Nominations to June 26, 2010
  • Mark Your Calendars to Attend SDCMS' July 22, 2010, Membership Social
  • "Microsoft Outlook for Busy Docs" SDCMS Seminar - Saturday, August 7, 2010, 8:00am-11:30am
  • Physician Requirements for Cancer Reporting in California (May 28, 2010)
  • Alzheimer's Association Physician Survey: Dementia Education Needs
  • SDCMS SEMINARS / WEBINARS / EVENTS
  • SAN DIEGO COUNTY HEALTHCARE EVENTS

STATE

Blue Cross Will Not Pay for Post-surgical Complications
Typically, surgical procedures have a global days assigned. In that global day period, the plans will not pay for post-op management. The concept with Medicare and all other payors is that the cost to manage that surgery and all pre- and post-op visits is incorporated into the pricing for the surgery; however, most payors will allow payment for follow-up procedures - such as incision and drainage - if it requires a return to an operating room/procedure room and is submitted with a modifier -78. Medicare pays the claims somewhat differently than the commercial payors, but most payors will usually allow these types of procedures as long as it's serious enough to require a return to the operating/procedure room. Most, however, will not consider payment for minor incision and drainage procedures if they are done bedside or in the physician office. With Blue Cross, even modifier -78 will not bypass this edit effective 08/23. In essence, Blue Cross is saying that they will not, under any circumstances, consider payment for post-surgical complications.

DHCS Announces Fee-for-Service Provider Payment Delay
The California Department of Health Care Services (DHCS) announced it will delay payments for one week at the end of June and pay those claims out of the 2010-2011 fiscal year budget. This "check-write" delay will impact fee-for-service providers in the following programs:

  • Medi-Cal
  • Healthy Families
  • Child Health and Disability Prevention
  • California Children's Services
  • Expanded Access to Primary Care
  • Genetically Handicapped Persons Program
  • Abortion Services

New CMA ON-CALL Document #1250, "Ten Strategies to Protect Quality Through Medical Staff Self-governance"
CMA has identified 10 steps that can be taken by medical staffs to increase compliance with Joint Commission and legal standards, reduce conflict between medical staffs and hospital administrations, and allow physicians to focus on taking care of patients. For more information, see CMA ON-CALL document #1250, "Ten Strategies to Protect Quality Through Medical Staff Self-Governance." For assistance with accessing SDCMS' members-only website, contact your SDCMS physician advocate, Marisol Gonzalez, at (858) 300-2873 or at MGonzalez@SDCMS.org.

Blue Cross Announces Changes to Prudent Buyer Contract
Anthem Blue Cross notified contracting physicians of impending changes to its Prudent Buyer Participating Physician Agreement (including but not limited to global surgery, anesthesia, modifier -59, sleep studies, multiple surgery reduction, and bundled services and supplies). The Prudent Buyer contract has also been amended to include automatic participation in the Blue Cross Medicare Advantage PPO, which you can opt out of. If you do not want to participate in this product, you can opt out by notifying the insurer in writing by July 30. If you have questions about the Prudent Buyer contract amendments, call Blue Cross' provider care department at (800) 677-6669. Physicians should also be aware that they have the right to terminate an agreement if a material change is not beneficial to their practice. If you object to the proposed amendments and wish to terminate your contract, you can do so by notifying Blue Cross in writing within 45 business days of receipt of the notice (or no later than July 30). To help physicians negotiate and manage complex third-party payor agreements, CMA has published a contracting toolkit, "Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations-A Focus on Payor Contracting." This toolkit is available free to members at CMA's members-only website.

Update on SB 726 - a Bill That Would Erode the Corporate Practice of Medicine Ban
On June 17, 2010, SB 726 (Ashburn) - a bill that would have eroded the ban on the corporate practice of medicine - died on the Assembly floor!

Federal Medi-Cal Audits to Begin in August
CMS will be conducting audits of Medicaid claims in California. The audit is part of the federal Payment Error Rate Measurement (PERM) Program, mandated by the Improper Payments Information Act of 2002. The purpose of PERM is to estimate the number of payment errors made in the Medicaid programs of all 50 states and report back to Congress with an "improper payment estimate." Five hundred California Medi-Cal claims will be selected for audit over the course of one year, approximately 130 claims per quarter. Audited claims will have dates of service of October 1, 2009, to September 30, 2010. Providers whose medical records have been selected for review will begin receiving written requests for medical records beginning this August. DHCS is urging all providers to comply with requests for medical records from the federal contractors or DHCS. If you fail to submit the requested records, an error will be counted against California and you will be required to refund the claim payment amount to DHCS. Your cooperation will help ensure that the audit results are accurate and that California retains its much-needed federal matching monies for the Medi-Cal program. For more details on the federal audits, see DHCS's March 2010 Medi-Cal Update newsletter. The DHCS Audits and Investigations Unit has also been stepping up anti-fraud efforts, including investigations of physicians and other providers. This year's budget proposal includes a request for 38 additional DHCS positions to implement an anti-fraud initiative, with an estimated net savings of $26.4 million resulting from the increased audit efforts. For more information on Medi-Cal audits, see CMA On-Call document #0626, "Medi-Cal Audits." CMA also recently hosted a webinar on Medi-Cal fraud and abuse. The previously recorded webinar is available for on-demand viewing to members only.

State Auditor Finds That Medi-Cal TAR Process Should Be Streamlined
The Bureau of the State Auditor last week released its long-delayed audit of Medi-Cal's Treatment Authorization Request (TAR) process. CMA requested the audit, which was coauthored by Assembly members Ted Lieu (D-Torrance) and Jim Beall (D-San Jose). In its report, the auditor found that of all the services that require TARs, 40 percent of them have denial rates of less than 4 percent. That means that from 2007 to 2009 the state spent approximately $14.5 million processing four million medical TARs for services and procedures that are very rarely denied. Since 96 percent of these TARs are granted, the process does little more than delay treatment and increase administrative costs. The auditor recommended that the Department of Health Care Services (DHCS) either create a system for automatically adjudicating these TARs or eliminate the need for them altogether. CMA has been advocating for a more efficient TAR process for many years. Over the last six years, the TAR process has been a target for review; however, changes have yet to materialize. The need to change the TAR system was recognized by a 2003 Medi-Cal Policy Institute report and in the 2005 California Performance Review. Both stated that the process was slow, inefficient, inconsistent, and outdated. The TAR program costs the state $1.5 billion to administer and creates considerable added paperwork for physicians serving Medi-Cal patients. CMA also supported legislation last year that would have reformed the TAR process. That bill was held due to concerns about the state budget. View the auditor's report on the California State Auditor's website.

Appeal, Appeal, Appeal
Practice revenue is lost when claims are underpaid, delayed, or inappropriately denied. Studies have shown that only half of physician offices appeal. Yet, a CMA survey found that 68 percent of physicians who do appeal receive additional monies. Payors are required to maintain a free, optional, fair, fast and cost-effective provider dispute resolution process to resolve both contracted and non-contracted physician disputes (28 C.C.R. §1300.71.38, Insurance Code §10123.137). Appeal in five easy steps:

  1. Review the EOB to determine why the claim was denied, adjusted, or contested.
  2. Determine if the payor requires the use of a specific appeal form.
  3. Prepare your appeal.
  4. File your appeal as soon as possible and no later than the time frame indicated below.
  5. If your appeal is unsuccessful, consider a second level appeal and file a formal complaint with the appropriate regulator.

Click here for more information.

Ask the Expert: "Payment in Full"

  • QUESTION: I was underpaid for a service by a payor. The check that accompanied the EOB states that the amount constitutes "payment in full." Does acceptance of the check mean that the physician has waived her right to appeal the claim for additional payment?
  • ANSWER: No. If you strike out or otherwise delete that notation before it is cashed, acceptance of the check does not mean that the payor's liability on the claim is satisfied (Civil Code §1526). Thus, physicians who receive such checks should strike out the notation and pursue their appeal rights.
  • CMA RESOURCE: CMA ON-CALL document #0146, "Payment Denials by Managed Care Plans and IPAs."

FEDERAL

Clarifying the Distinction Between "Private Contracting" and "Balance Billing"
"Private contracting" is a statutory and regulatory term. By definition, it means that insurance is excluded from the patient-physician relationship. The physician enters into a contract, and the patient agrees to pay the physician's own rates for needed services, without insurer interference. The insurer (including Medicare) is not a party to that contract and does not have to pay anything to the patient or the physician. Under the Medicare program, physicians who enter into a private contract with any patient must sign a written contract and an affidavit and agree to forego Medicare payments for any patients for a period of two years; they must opt out of the program.

  • Many physicians and state and specialty societies talk about private contracting "without penalty to the patient or the physician." This term often relates to the opt-out requirements under Medicare - physicians should not be required to opt out for two years, nor should they have to enter into contracts with all patients if they choose to enter into a contract with one patient.

"Balance billing" limits are in effect for Medicare physician payments. Physicians who do not choose "participating" status or who accept assignment on a case-by-case basis may balance bill patients up to 115% of the allowed Medicare fee schedule amount (although the allowed fee schedule amount is 5% lower for physicians who exercise this option, so the resulting payment is not fully 15% more than that allowed for a "participating" physician).

  • Many physicians and state/specialty societies that talk about private contracting "without penalty to the patient or the physician" really mean that they want to eliminate balance billing limits. They want the physician to be free from insurance (Medicare) hassles, but they don't want to ask the patient to forego compensation from the insurance company. Those who use the "private contracting" term incorrectly confuse the issue. Revising the private contracting statute will not achieve their goal; what they actually want AMA to do is advocate for eliminating the balance billing limits.

Reminder: PECOS Enrollment Deadline Is July 6, 2010
Physicians who have not updated their Medicare enrollment information in the past five years may need to fill out another application or risk facing payment problems for ordered or referred services. Under new rules, which take effect July 6, Medicare is authorized to reject claims if an ordering or referring physician is not identified in Medicare's Internet-based PECOS enrollment system. Thousands of otherwise acceptable Medicare claims could go unpaid merely because they were submitted by providers who enrolled in Medicare before the PECOS database was developed. Don't know if you're in PECOS? CMA has developed a step-by-step guide to walk you through the process, from determining if you are already in PECOS to accessing the Internet-based PECOS enrollment system. CMA also hosted a PECOS enrollment webinar with Palmetto, California's Medicare contractor, is available for on-demand viewing to members only at CMA's members-only website.

Questions Regarding E-prescribe Bonuses

  • QUESTION: When are 2009 e-Rx bonuses going to be paid? ANSWER: We expect this to be paid in Sept or Oct of 2010.
  • QUESTION: Will there be an appeals process if a physician is not paid? ANSWER: There is an inquiry support process but no formal appeals for the 2009 program.
  • QUESTION: Why can't the bonus be paid earlier in the year? ANSWER: Part of the issue is we need to collect information via claims and we allow EPs to submit this data through the first 2 months of the following year (i.e., through the end of February. The data does not make it to CMS' contractors for calculation for several weeks thereafter. Any data that needs further scrutiny can affect the timelines as well.
  • QUESTION: Can we expect the HITECH bonuses to be paid in a similar manner? ANSWER: As the program and data collection method (at least for 2011) is different, I cannot answer this question. [The final rule is also still being worked on by a different CMS component.

LOCAL

American Red Cross Extends Deadline for Real Heroes Nominations to June 26, 2010
Residents of San Diego and Imperial counties are encouraged to submit nominations for individuals or groups who have shown extraordinary courage and human compassion to help someone in need or to better their community. Winners will be honored at the 8th Annual Real Heroes Breakfast, a highly visible public affair with over 800 business and community leaders in attendance - to be held on September 30, 2010, aboard the USS Midway Museum from 7:30am to 9:30am. Click here or call (858) 309-1200 to nominate a hero or for more information on the Real Heroes Breakfast.

Mark Your Calendars to Attend SDCMS' July 22, 2010, Membership Social
To be held Thursday, July 22, 2010, from 6pm to 9pm at the Rock Bottom Restaurant and Brewery in La Jolla, 8980 Villa La Jolla Drive, La Jolla. Space is limited to 100 people, so please RSVP as soon as possible to Jen Ohmstede at (858) 300-2781 or at JOhmstede@SDCMS.org.

"Microsoft Outlook for Busy Docs" SDCMS Seminar - Saturday, August 7, 2010, 8:00am-11:30am
This three-and-a-half hour SDCMS members-only course on how to make Microsoft Outlook your servant and not your master. This will be a very, very practical and user-focused seminar. Please mark it down on your calendar and email me (Gehring@SDCMS.org) if you're interested.

MEDICAL

Physician Requirements for Cancer Reporting in California (May 28, 2010)
Recent media reports have described concerns about increased cancer cases in some neighborhoods of Carlsbad. As part of the response, the County of San Diego Health and Human Services Agency (HHSA) is working with the California Cancer Registry (CCR) to ensure that all recently diagnosed cancer cases are being reported in a timely fashion as required by law. HHSA reminds all local healthcare providers to report cancer cases to the CCR as soon as possible and not longer than six months after the date of initial cancer diagnosis. This includes patients treated in hospitals, as well as outpatient, settings. For information on cancer reporting requirements, please download "Physician Requirements for Cancer Reporting in California." A confidential cancer reporting form is included in this online document. Click here for more information about the HHSA response to cancer concerns in Carlsbad.

Alzheimer's Association Physician Survey: Dementia Education Needs
The Alzheimer's Association is developing a dementia-specific, CME educational series for physicians and allied healthcare professionals. To ensure that we focus on the most pertinent topics and modes of delivery we are soliciting input from the physician community. We would be grateful if you could complete this short survey, which should take no more than five minutes. Thank you for your participation!

SDCMS SEMINARS / WEBINARS / EVENTS
For further information on or to register for any of the following SDCMS seminars, webinars, and events, contact Sonia Gonzales at (858) 300-2782 or at SGonzales@SDCMS.org.

  • JUL 15 (THU) • IT Overview Seminar/Webinar • 11:30am-1:00pm
  • JUL 20 (TUE) • "The Employee's Role in Decreasing Liability Risks in the Physician Office" Risk Management Webinar • 11:30am-12:30pm
  • JUL 21 (WED) • "The Employee's Role in Decreasing Liability Risks in the Physician Office" Risk Management Webinar • 6:30pm-7:30pm
  • JUL 22 (THU) • SDCMS Membership Social • 6:30pm-9:00pm • Rock Bottom Restaurant and Brewery, La Jolla • SDCMS Members + Guest, Limited Spacing, RSVP Required • JOhmstede@SDCMS.org
  • AUG 7 (SAT) • "Microsoft Outlook for Busy Docs" Seminar • 8:30am-12:00pm • Gehring@SDCMS.org
  • AUG 18 (WED) • "OSHA Updates" Seminar/Webinar • 11:30am-1:00pm
  • AUG 25 (WED) • "HIPAA Updates" Seminar/Webinar • 11:30am-1:00pm

 

SAN DIEGO COUNTY HEALTHCARE EVENTS
To submit a community healthcare event for possible publication, email KLewis@SDCMS.org. Events should be physician-focused and should take place in San Diego County.

"Our fatigue is often caused not by work, but by worry, frustration, and resentment."
— Dale Carnegie, American Writer and Lecturer (1881-1955)

Read more about: Healthcare News and Updates, SDCMS News and Updates, SGR, News You Can Use

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