Ask Your Physician Advocate

QUESTION: I received a contract from a medical group that contains a provision about “reciprocity” that concerns me. I believe this medical group may function as a silent PPO. Can someone take a look at the clause and double-check my suspicion?

ANSWER: CMA’s Center for Economic Services reviewed this section and agreed that it does raise a red flag. The reason for the concern is that if you do contract with a group that has a provision in the contract such as this one, and you negotiate a certain rate, this will be the same rate for the other groups in which this plan has reciprocity. When physicians see this type of wording in their payer contracts, they should ask the plan who they have reciprocity with. You can decide to either negotiate this type of provision with the plan, or you can ask them to completely remove it from the contract.

QUESTION: Recently, I overheard a conversation about United Healthcare’s losing a battle over a progressive fee schedule. Could you give me the details on that?

ANSWER: In response to CMA advocacy, United Healthcare has agreed to stop using its “progressive fee schedule” methodology, which CMA believes to be a violation of state fair payment laws. Currently, United makes significant changes to its fee schedules under the guise of “routine maintenance” without notifying physicians or giving them the opportunity to cancel their contracts. Last year, CMA asked the Department of Insurance to force United to comply with state law, which requires insurance companies to give contracted physicians 45 days’ notice of any material changes to their contracts.

United’s progressive fee schedules are developed using third-party data (such as Medicare’s relative value units). According to United, “routine maintenance” occurs when it “mechanically incorporates revised information created by a third party that is the source for a portion of the fee schedule.” Physicians have reported to CMA that payments for some CPT codes have been reduced by as much as 10 percent during such “routine maintenance.” These fluctuations make it difficult for physicians to predict the exact amount they will be paid.

More than 50 percent of physicians contracted with United Healthcare in California — approximately 25,000 physicians — are on these so-called progressive fee schedules. Affected physicians were recently notified by certified mail of United’s decision to eliminate the progressive fee schedule. Effective April 1, 2009, the fee schedule is fixed to 2008 CMS RBRVS. (Physicians will see no difference in their current reimbursement.) Included with the notice was a sample fee schedule.

CMA reminds physicians that before signing a health plan contract or contract amendment, it is important to know what value it will bring to your practice. Physicians do not have to accept bad contracts or contracts that are not mutually beneficial.

QUESTION: Is there a change in the way the Medical Board of California will be requiring physicians to track and report their CME credits as of 2009?

ANSWER: Yes. As of 2009, physicians will now be required to complete 50 CME hours during every two-year licensure period. Previously, physicians were required to complete 100 hours every four years. CMEs will also be calculated based on the physician’s personal license renewal date (the last day of the month of your birthday) and not the calendar year.