SBCMS News/Media

CMA objects to federal rule that would disrupt comprehensive women's health coverage

The California Medical Association (CMA) has filed formal comments objecting to a proposed federal rule that would change the way consumers are billed for health insurance exchange plans that cover abortion services.

The proposed Exchange Program Integrity rule would require plans to send two separate monthly bills to each policyholder: one bill for the non-Hyde abortion coverage (at least $1 per member per month) and one bill for all other services. This would mean consumers would have to pay their monthly premium in two separate transactions.

CMA believes the proposal threatens to disrupt coverage for consumers nationwide, with particularly harmful impacts for California. California law requires most health plans to cover abortion services, and 1.395 million people were enrolled in 2018 coverage in a Covered California qualified health plan.

Two separate bills will cause confusion and member abrasion, particularly if the additional hassle is for a single dollar. Enrollees will be confused by an “other premium” bill for the majority of their coverage premium and a separate $1 non-Hyde premium and may, either out of confusion, or lack of awareness of the consequences, not pay the $1—putting them at risk of having their policy cancelled.

The proposed rule would also create additional costs and administrative burdens for health plans, which could decrease plans’ willingness to offer comprehensive women’s health coverage in the exchanges.

Anthem issues new ID number for some patients

Anthem Blue Cross has issued new identification numbers and cards for a number of its members. New ID cards containing the new ID number were mailed to all affected members in late December. Providers are encouraged to make copies of each patient’s insurance card at the time of visit to verify the member’s identification number.

Anthem advises that claims submitted with an incorrect ID number will be returned to the provider for correction and resubmission with the correct ID. Providers will need to contact their patients to obtain their updated identification number. If a member does not recall receiving a new ID card in December or misplaced an ID card, the member can contact Anthem to verify their ID using one of the following options:

• Call the Anthem member services number on their ID card
• Log into their member account at www.anthem.com/ca
• Use Anthem's mobile app (Anthem Anywhere) to access their electronic ID card

Golden Shore Medical Group to shut down following Molina contract termination

The California Medical Association (CMA) has learned that Molina Healthcare has terminated its contract with Golden Shore Medical Group. The plan filed requests in late 2018 with the California Department of Managed Health Care (DMHC) to transfer its enrollees to other delegated groups and the request was approved by the Department on January 11, 2019.

According to Molina’s block transfer filing with DMHC, the termination was the result of the parties’ inability to agree on contractual terms. As a result of the termination, Golden Shore has announced to its network physicians that it will close its doors on January 31, 2019.

The plan filings with DMHC indicate approximately 80,000 Molina enrollees, 94 percent of which are Medi-Cal patients, will be affected in Sacramento, San Bernardino, Riverside, Orange and Los Angeles counties as follows:

*Note: there are approximately 26 receiving medical groups/IPAs. Those listed represent medical groups/IPAs that will receive 200 or more enrollees.

The plan filing indicates that only nine percent of enrollees are expected to be able to retain their current primary care physician.

Four other plans also delegated a small number of enrollees to Golden Shore—Brand New Day, Central Health Plan, Easy Choice and Aetna. CMA is gathering more information on the total number of enrollees with these four plans and which delegated groups will receive the enrollees.

Claims for services provided through January 31 should be submitted to Golden Shore for payment. If claims have been submitted to Golden Shore and are not being paid timely, physicians should contact the plan directly.

CMA encourages physicians to be diligent in obtaining updated insurance information from Golden Shore patients and to verify eligibility at the time of scheduling, if possible, to avoid unnecessary patient confusion and denials of payment for services rendered.

Patients may also be able to continue to see their physicians, even if they the physician is not contracted with the patient’s new delegated entity, under California’s continuity of care law. Under continuity of care laws, patients with an acute condition, serious chronic condition, duration of a pregnancy, duration of a terminal illness, and care of children between birth and 36 months may qualify to request continuity of care. Additionally, patients that have received an authorization for a surgery or other procedure to be performed within 180 calendar days of January 31, may be eligible to request continuity of care. To request continuity of care, patients should call the health plan number on the back of their ID cards.

For more information on continuity of care requirements, see CMA health law library document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.” (Health law documents are available free to CMA members. Nonmembers can purchase documents for $2 per page.)

CMA will provide more information on Molina’s transition once we received updated information on the receiving groups. Practices that are experiencing problems with Golden Shore or issues resulting from the contract termination are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

UnitedHealthcare delays outpatient advanced radiology policy until February 1

Citing the need for additional time for communication and optimal rollout, UnitedHealthcare (UHC) has delayed implementation of its outpatient advanced radiology policy until February 1, 2019. 

The new UHC policy—originally scheduled for implementation on Jan. 1—requires prior authorization for advanced imaging procedures, including certain magnetic resonance imaging, magnetic resonance angiography and computed tomography imaging procedures, when performed in the outpatient hospital setting.  Under UHC’s Outpatient Radiology Notification/Prior Authorization Protocol, a site of care review will be required for these advanced imaging services when performed in the outpatient hospital.

Site of care reviews will not be done as part of the prior authorization process if a procedure will be performed in a free-standing diagnostic radiology center or an office setting. Additionally, authorization will not be required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay.

The UHC policy is similar to a policy implemented by Anthem Blue Cross in December 2017.

For more information on the new policy, UHC has published the Site of Care for Outpatient MR/CT Services FAQ or physicians can visit the Radiology Prior Authorization and Notification page on the UHC website.

The California Medical Association will be closely monitoring this policy as it is implemented to better understand how it will affect physician practices and patient care.

UnitedHealthcare to implement outpatient advanced radiology policy

Effective January 1, 2019, UnitedHealthcare (UHC) will require prior authorization for certain advanced imaging procedures when performed in the outpatient hospital setting.

As highlighted in the UnitedHealthcare Network Bulletin October 2018, certain magnetic resonance imaging, magnetic resonance angiography and computed tomography imaging procedures will now be subject to a site of care review when performed in the outpatient hospital under UHC’s Outpatient Radiology Notification/Prior Authorization Protocol.

Site of care reviews will not be done as part of the prior authorization process if a procedure will be performed in a free-standing diagnostic radiology center or an office setting. Additionally, authorization will not be required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay.

The UHC policy comes on the heels of a similar policy implemented by Anthem Blue Cross in December 2017.

The California Medical Association is in the process of evaluating the new UHC policy to better understand how it will affect physician practices and patient care. For more information on the new policy, UHC has published the Site of Care for Outpatient MR/CT Services FAQ or physicians can visit the Radiology Prior Authorization and Notification page on the UHC website.

First-ever TRICARE open enrollment begins November 12

Beginning November 12 and running through December 10, 2018, TRICARE will initiate its first ever open enrollment period for beneficiaries to enroll in or change their TRICARE Prime or TRICARE Select health plan coverage. Beneficiaries already enrolled who want to continue with their current plan without changes do not need to do anything. Any changes made during the 2018 open enrollment will be effective January 1, 2019. Outside of open enrollment, beneficiaries enrolled in Prime or Select will only be able to make a plan change if they have a qualifying life event. Previously, beneficiaries could change plans at any time.

TRICARE referral requirements, deductibles and copayments/cost-shares vary by plan type. Physicians are urged to be diligent in verifying patient eligibility and benefits on or after January 1, 2019, to avoid unexpected higher out-of-pocket costs for patients. Visit www.tricare-west.com for online eligibility and benefit tools.

TRICARE For Life doesn’t require enrollment. TRICARE open enrollment also does not apply to the premium-based plans listed below. These plans will continue to offer continuous open enrollment throughout the year:

• TRICARE Retired Reserve
• TRICARE Reserve Select
• TRICARE Young Adult
• Continued Health Care Benefit Program

For more information on the TRICARE open enrollment, visit www.tricare.mil/openseason.

Some Medi-Cal managed care plans slow to distribute Prop 56 funds

In May, the California Department of Health Care Services (DHCS) distributed the Proposition 56 supplemental funds for FY 2017-2018 to the Medi-Cal managed care plans. At the California Medical Association’s request, DHCS specified that plans must distribute the funds to providers within 90 days. However, the 90-day window ended August 31 and CMA has received complaints from physicians that some plans have still not issued supplemental payments.

The supplemental payments are a result of the California Health Care, Research and Prevention Tobacco Tax Act of 2016 (Prop 56), which created new revenues dedicated to the Medi-Cal program. Physicians receive supplemental payments in both fee-for-service and Medi-Cal managed care when providing Medi-Cal services under certain CPT codes. 

The eligible codes and amounts approved for additional payment for FY 2017-2018 are:

The supplemental payments bring Medi-Cal reimbursement rates for these codes up to about 65 percent of Medicare rates.

Practices that believe they have not received their supplemental payments are strongly encouraged to reach out to the plan contact for Proposition 56 directly.

Physicians with questions or concerns about Prop 56 payments are also encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

IEHP completes termination of Vantage contract; three plans extend termination dates

The California Medical Association (CMA) has confirmed that Inland Empire Health Plan (IEHP) completed its contract termination with Vantage on August 31, 2018.

IEHP transitioned its 273,000 covered lives to the following delegated groups:

According to IEHP, 99.4 percent of enrollees retained the same primary care physicians.

The plan’s block transfer filing indicated that the termination was the result of conduct by Vantage that resulted in the inappropriate delay, denial or modification of authorizations for services and care provide to IEHP’s Medi-Cal managed care enrollees. According to IEHP, Vantage had, over a period of years, engaged in conduct that violates state and federal laws regarding the prompt and timely payment of provider claims, includes manipulating and falsifying claims, banking records and audit reports.

Blue Shield of California, Blue Shield of California Promise Health Plan (formerly Care1st) and Molina had also issued notices of their intent to terminate if Vantage failed to correct the breaches, but have extended their termination dates to November 30, 2018.

Practices experiencing any payment issues for Vantage claims for services on or before the IEHP termination date are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

What you need to know about Blue Shield of California's Care1st integration

On January 1, 2019, Blue Shield of California will complete the integration of Care1st Health Plan into its operations, and Care1st’s name will change to Blue Shield of California Promise Health Plan. The newly renamed health plan will remain a separate company and a wholly owned subsidiary of Blue Shield of California.

Care1st physicians serving Medicare Advantage HMO, Medi-Cal or Cal MediConnect members will not need to contract with Blue Shield of California to continue providing services, and participating physicians will receive a mailed contract amendment later this year that reflects the name change. The contract amendment only refers to the name change and will not impact reimbursement rates or other material changes.

In addition, the migration of member and provider data to improve information-technology infrastructure will result in several changes requiring some action on the part of current Care1st network providers, including new provider ID numbers, member ID numbers and member ID cards, as well as changes to submission processes for encounter data.

Greg Buchert, M.D., MPH, president and CEO of Care1st, and a California Medical Association (CMA) member for 27 years, has provided a Q&A for CMA members to learn more about the transition – learn more by downloading here.

Coding Corner: CPT reporting for preventive medicine services

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

Preventive medicine services, or “well visits,” are evaluation and management (E/M) services provided to a patient without a chief complaint. The reason for the visit is not an illness or injury (or signs or symptoms of an illness or injury), but rather to evaluate the patient’s overall health, and to identify potential health problems before they manifest.

The CPT® codebook includes a dedicated set of codes to describe preventive medicine services, as follows:

• 99381 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than 1 year)
• 99382 …early childhood (age 1 through 4 years)
• 99383 … late childhood (age 5 through 11 years)
• 99384 …adolescent (age 12 through 17 years)
• 99385 …18-39 years
• 99386 … 40-64 years
• 99387 …65 years and older
• 99391 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than 1 year)
• 99392 …early childhood (age 1 through 4 years)
• 99393 … late childhood (age 5 through 11 years)
• 99394 …adolescent (age 12 through 17 years)
• 99395 …18-39 years
• 99396 … 40-64 years
• 99397 …65 years and older

Code assignment is determined by the patient’s age (as detailed in the code descriptor), and whether the patient is new (99381-99387) or established (99391-99397). CPT® applies a “three-year rule” to determine “new” vs. “established” status. A patient is established if any physician in a group practice (or, more precisely, any physician of the same specialty billing under the same group number) has seen that patient for a face-to-face service within the past 36 months. The “Decision Tree for New Vs Established Patients” in the Evaluation and Management Services Guidelines portion of the CPT® codebook can help you to select the appropriate patient status.

Service Content Varies by Patient Circumstance
Preventive medicine services must include a comprehensive history and examination, and age-appropriate anticipatory guidance. In the context of preventive medicine services 99381-99397, a comprehensive exam is not the comprehensive exam as defined by either the 1995 or 1997 Evaluation and Management Documentation Guidelines. Instead, the exam should reflect an appropriate assessment, given the specific patient’s age and sex. For example, the specifics of the exam will differ for a 4-year-old male and a 22-year-old female.

Services for a young child will assess physical growth (height, weight, head circumference) and developmental milestones such as speech, crawling and sleeping habits. Anticipatory guidance may include use of car seats and other safety issues, introducing new foods, etc.

An adolescent preventive service may include scoliosis screening, assessment of growth and development, and a review of immunizations. Anticipatory guidance may focus on developing positive health habits and self-care, including discussion of drug, alcohol and tobacco use and sexual activity.

A comprehensive preventive visit for an adult female patient will include a gynecologic examination, Pap smear and breast exam. An adult male’s exam would include an examination of the scrotum, testes, penis and the prostate for older patients. Anticipatory guidance may focus on issues of health maintenance, such as alcohol and tobacco use, safe sex practices, nutrition and exercise. The patient’s employment status and other family issues may be discussed. As patient age advances, cholesterol levels, blood sugar and prostate-specific antigen testing may become increasingly relevant.

Diagnoses Must Support Preventive Nature of the Visit
Every billed service must be supported by an ICD-10 code(s) that describe the reason for that service. In the case of a well visit—because there is no patient complaint—you should turn to so-called “Z codes” (Factors influencing health status and contact with health services). For example:

• Z00.110  Health examination for newborn under 8 days old
• Z00.111 Health examination for newborn 8 to 28 days old
• Z00.121 Encounter for routine child health examination with abnormal findings
• Z00.129 Encounter for routine child health examination without abnormal findings
• Z00.00 Encounter for general adult medical examination without abnormal findings
• Z00.01 Encounter for general adult medical examination with abnormal findings
• Z01.411 Encounter for gynecological examination (general) (routine) with abnormal findings
• Z01.419 Encounter for gynecological examination (general) (routine) without abnormal findings

You should also code for any abnormalities found, regardless of whether the finding requires an additionally reported service.

Testing and Problem-Focused Testing Are Separate
Per CPT® coding guidelines:

If an abnormality is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service, and if the problem or abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should also be reported. Modifier 25 should be added to the office/outpatient code to indicate that a significant, separately identifiable evaluation and management service was provided on the same day as the preventive medicine service.

To determine whether a problem requires “significant” work, consider whether the available documentation is sufficient to support each service (the preventive service and the problem-oriented service), separately.

Additionally, per CPT® coding guidelines, as supported by CPT Assistant (April 2005):

The codes in the preventive medicine services include the ordering of appropriate immunization(s) and laboratory or diagnostic procedures. The performance of immunization and ancillary studies involving laboratory, radiology, other procedures, or screening tests identified with a specific CPT code are reported separately.

Payor Coverage May Vary
The Affordable Care Act (ACA) requires insurers to cover recommended preventive services without any patient cost-sharing, but exact coverage and reporting requirements may vary from payor to payor. As CPT Assistant (April 2005) notes:

Codes 99381-99397 are used to report the preventive evaluation and management (E/M) of infants, children, adolescents, and adults. The extent and focus of the services will largely depend on the age of the patient. For example, E/M preventive services for a 28-year-old adult female may include a pelvic examination including obtaining a pap smear, breast examination, and blood pressure check. Counseling is provided regarding diet and exercise, substance use, and sexual activity.

Therefore, based upon this information, it would not be appropriate to separately report for a pelvic exam including obtaining of the pap smear, nor the breast exam as these services are considered part of a comprehensive preventive medicine E/M services.

Although this reporting method reflects the intent of CPT coding guidelines, third-party payers may request that these services be reported differently. Third-party payers should be contacted for their specific reporting guidelines.

Note: Although the CPT Assistant article cited pre-dates the ACA, the advice to contact your payers regarding their reporting requirements remains valid.

Be aware, as well, that Medicare reporting requirements, as stipulated by the Centers for Medicare and Medicaid Services (CMS) often differ from CPT® guidelines. For more information about Medicare Preventive and Screening Services, visit the CMS website.