SBCMS News/Media

Medicare transition is three weeks away

September 16, 2013, is the cutover date for transition of the Medicare Part B fee-for-service contractor from Palmetto GBA to Noridian. Although every effort has been made to minimize the burden to practices and to ensure that physicians continue to receive their Medicare payments in a timely fashion after the transition, physician practices will have to make some changes in their processes. Practices are encouraged to review the resources available to you to ensure you are aware of and prepared for the transition.

Physician practices that submit their claims electronically, especially if they are currently direct submitters to Palmetto, may want to consider Early Boarding to avoid any possible issues following the transition. The last day to enroll for Early Boarding is August 30, 2013.

Practices are also encouraged to review the resources available regarding the transition:

CMA’s Medicare Transition webpage: CMA has created a dedicated Medicare transition webpage, www.cmanet.org/medicare-transition, offering practices the ability to access updates and important information regarding the transition in one easy-to-access to location. All resources related to the Medicare transition will be accessible through this page.

CMA’s Medicare Transition Guide: This guide, which members can download free from the CMA website, contains information on the transition dates, what will remain the same with the transition and what will change, Noridian’s online provider portal, what practices can do to prepare for the transition and links to additional resources and ways to stay apprised of new information on the transition. The guide also includes a comprehensive preparation checklist.

Noridian’s transition website: The Noridian transition website includes information on what’s new/changing and what will remain the same during and after the transition.

CMA Practice Resources: CMA Practice Resources (CPR) is a free monthly newsletter from CMA’s practice management experts that focuses on critical payor and health care industry issues, including the Medicare transition, and how these issues directly impact the business of a physician practice. To sign up, visit the CMA website (www.cmanet.org/newsletters) or contact CMA Member Services at (800) 786-4262 or memberservice@cmanet.org.

CMA Content Alerts: The CMA website allows registered users to create custom content alerts on the topics that are of interest to you. Once signed up, you will be notified any time there is new content posted in one of your interest areas. To sign up to receive Medicare alerts, users should visit their account dashboard on the CMA website and click on “my alerts,” then under "New Content Alerts" click on the "Alert Settings" tab, and select “Insurance Reimbursement -> Medicare.”

Contact: CMA reimbursement help line, (888) 401-5911 or mkelly@cmanet.org.

MICRA: Haven't we all seen this before?

For nearly four decades California trial attorneys have been trying to rewrite the Medical Injury Compensation Reform Act (MICRA).

By now, you’ve likely heard the main narrative spun by the trial lawyer-backed Consumer Watchdog and other MICRA opponents – 38 years is too long for a law such as MICRA to exist without being updated in some fashion.

Oddly enough, Consumer Watchdog and others are quick to leave out the fact that the only time MICRA was successfully altered, trial lawyers agreed to back off in exchange for a bigger piece of the pie when it came time to calculate attorney fees.

The update, which took place as part of the now infamous “Napkin Deal,” saw MICRA’s tiered method of calculating attorney fees altered in a way that allowed attorneys to assess fees at a much higher rate than what was originally allowed for under the law. To an outsider, the changes might look subtle, but on a hypothetical award of $600,000, attorney fees following the Napkin Deal would be $161,666. Before the deal, fees would have been only $101,666.

That’s an extra $60,000 going into the pockets of trial lawyers rather than the consumers they swear to be protecting. Adding to the irony is the fact that, in exchange for the larger pay day, trial attorneys promised to stop pushing for changes to MICRA for at least five years.

Now, the same MICRA opponents are calling for reform, using the tagline “38 is too late.” However, nowhere in their campaign literature does it mention that for five of those years, attorneys were sitting on their hands after being bought off in one of the most infamous backroom deals in California’s political history.

It’s also worth mentioning that the entire reason the Napkin Deal took place was that the trial lawyers were threatening to launch a ballot initiative fight if action wasn’t taken by the Legislature.

This all sounds a little familiar, doesn’t it?

In short, the last time trial lawyers called for reforms to MICRA, they found a way to circumvent some of the largest consumer protections built into law and swore to stop advocating for consumers in exchange for a fatter paycheck.

Can we really expect them to behave any differently this time around?

The California Medical Association (CMA) and our allies have amassed more than $28 million to protect MICRA from the trial attorneys’ latest repeal efforts. In August alone, groups such as the California Hospital Association, the Doctor’s Company, the California Dental Association, the Medical Insurance Exchange of California, NORCAL Mutual Insurance Company and the Cooperative of American Physicians have all put up multi-million dollar figures to derail these efforts. Our coalition is strong, but the help of individual CMA members will still go a long way to protect MICRA.

To learn more about MICRA and how you can help in the fight, visit www.cmanet.org/micra.

MICRA Update: Crunch time in the Capitol

A little more than three weeks remain in the 2013 legislative session, which means both sides in the growing fight over California’s Medical Injury Compensation Reform Act (MICRA) are working hard to woo members of the state Assembly and Senate over to their side of the issue.

In the days following the Legislature’s return from its summer recess, the California Medical Association (CMA) and other members of the Californians Allied for Patient Protection began blanketing legislative offices with letters of support for the historic patient and provider protections built into MICRA. So far, representatives from public safety groups, labor organizations, local governments and provider organizations have echoed the same message to California lawmakers:

MICRA is a proven success. It benefits California patients and providers and must be protected by our elected officials.

MICRA supporters will continue their aggressive advocacy in the coming weeks, working to ensure that members of the Legislature are not mislead by deceitful trial attorneys hoping to increase their own bottom line.

Of course, MICRA opponents are also working to win hearts and minds in Sacramento.

Last week, the trial-attorney-backed Consumer Watchdog, the same faux-grassroots organization behind the proposed ballot initiative to scuttle MICRA, hosted a briefing for legislative staffers entitled “38 years later: MICRA and its Casualties - A Case for Change.”

During the briefing, representatives from Consumer Watchdog continued to co-opt the stories of victims of medical negligence in an effort to raise MICRA’s cap on non-economic damages. The briefing was blatant attempt to try and win support for a potential legislative amendment to MICRA, one which would need to take place via an eleventh-hour, gut-and-amend type strategy.

California’s trial attorneys attempted a similar, yet much more narrowly focused, maneuver last legislative session, only to have their bill fail with a remarkably low number of votes. While it remains unlikely that they risk the embarrassment of a similar failure this session, we won’t know for sure until the Legislature gavels out on September 13.

CMA will keep members up-to-date on developments.

In the meantime, MICRA’s most ardent supporters continue to prepare for an all-out-defense of the law. In the month of August alone, groups such as the California Hospital Association, the Doctor’s Company, the California Dental Association, the Medical Insurance Exchange of California, NORCAL Mutual Insurance Company and the Cooperative of American Physicians have all put up multi-million dollar figures to defeat the trial attorney’s proposed ballot initiative.

These donations, along with those made by CMA and other supporters have raised the total sum for the committee dedicated to MICRA’s defense to more than $28 million.

These figures may seem larger than life, but defeating a well-funded initiative campaign is no small task. Every dollar raised in MICRA’s support will be used to ensure that California’s patients have access to quality care and that your practice’s future is not compromised by the greed of the state’s trial attorneys.

CLICK HERE to defend your ability to practice in California.

For more information on MICRA and how you can help, visit www.cmanet.org/micra.

Is your license renewing in September or October? Renew early to avoid delays with new online licensing system

The Medical Board of California is asking physicians that need to renew their medical licenses during September and October to do so early due to a planned disruption. According to the medical board, the Department of Consumer Affairs will transition to a new online licensing and enforcement system in mid-September 2013 and during this transition there could be disruptions in cashiering and other services. The disruption will affect both online and mail renewals.

To avoid any possible lapse in licensure due to processing delays, physicians whose licenses are set to renew in September and October are strongly encouraged to submit their renewal fees prior to September 1, 2013.

If you have questions, please contact the Medical Board at webmaster@mbc.ca.gov.

Are you ready for the next HIPAA compliance deadline?

The Department of Health and Human Services (HHS) released new regulations in January 2013 that made important changes to the privacy and security requirements under the Health Insurance Portability and Accountability Act (HIPAA). These new regulations, known as the HIPAA Omnibus Rule, implement many of the provisions of the Health Information Technology for Economic and Clinical Health (HITECH) Act. Covered entities have until September 23 to comply with these changes.

Physician offices will, at minimum, need to review and update their business associate agreements, office privacy and security policies and notice of privacy practices.

Some of the key changes made by the HIPAA Omnibus Rule include, but are not limited to, an updated definition of a business associate, new rules surrounding certain permitted uses and disclosures of protected health information (PHI), such as the sale of PHI and the use of PHI for fundraising and marketing, and rules controlling how patients can obtain medical records that are kept by a physician electronically. It also made significant changes to the breach notification rule.

For more information and for an updated sample notice of privacy practices and business associate agreement, see the California Medical Association’s (CMA) On-Call documents #4101 “HIPAA ACT SMART: Introduction to the HIPAA Privacy Rule” and #4103 “Business Associates.” These documents are available free to members in CMA's online health law library at www.cmanet.org/cma-on-call. Nonmembers can purchase documents for $2 per page.

CMA is also hosting a webinar, "HIPAA Compliance: The Final HITECH Rule," tomorrow, August 21 at 12:15 pm. If you are unable to participate in the live event, it will be available in the resource library shortly after the webinar for on-demand playback at your convenience.

Contact: CMA's Center for Legal Affairs, (800) 786-4262 or legalinfo@cmanet.org.

Federal regulations bring delays to ACA milestones

Deadlines and milestones relating to the Affordable Care Act (ACA) are beginning to slide, as the federal government gets a better picture of how capable it will be of implementing the massive changes called for in the law.

In July, the federal government announced that the penalty on employers for not providing employees health insurance would be delayed until 2015, while also scaling back income verification requirements that would have been used to determine subsidy levels for individuals purchasing coverage through the new insurance marketplaces.

The income verification announcement, which came as part of a 606-page rule published by the U.S. Department of Health and Human Services (HHS), said the requirement that exchanges verify consumers’ income and health insurance status would be delayed until 2015. As a result, consumers purchasing coverage through state-based insurance exchanges, which are scheduled to go live in January 2014, may be self-attesting to both their income and the availability of employer-sponsored coverage until federal verification processes are fully functional.

Under the ACA, consumers with incomes ranging from 138 percent to 400 percent of the federal poverty level will be eligible to purchase subsidized coverage through online marketplaces known as exchanges. In addition to the income requirements, enrollees must also not have access to health insurance through their employer to receive subsidies for exchange coverage.

HHS stated that a more comprehensive pre-clearance process is currently “not feasible” due to “operational barriers” and “a large amount of systems development on both the state and federal side, which cannot occur in time for October 1, 2013.” The agency did, however, pledge that “a more robust verification process” is in development and should be ready for the 2015 plan year.

With verification delayed until 2015, implementation of both the income and coverage requirements will be reliant on self-reporting by potential enrollees, leaving the system ripe for gaming, according to many observers. Such observers have cited figures like the 21 to 25 percent of those receiving the Earned Income Tax Credits who are not eligible. These and other enrollees, who may unintentionally misrepresent income, may also be in for an unpleasant surprise come tax filing for the 2014 tax year, as they will be asked to pay back all or a significant portion of excess subsidies received.

According to the rule, the federal government will be conducting random checks of coverage status and income levels in the states where they will be operating exchanges, but noted that the 17 state-based exchanges will have until 2015 to begin their random checks.

It remains to be seen how Covered California, one of the 17 state-based exchanges, will handle the new delay.

CMA, CMA Foundation partner for exchange's provider education grant program

The California Medical Association (CMA) and the CMA Foundation have submitted a joint application to Covered California, the state’s health benefit exchange, for a portion of the $3 million set to be awarded as part of its provider education grant program.

The program is expected to award grants to between three and six statewide organizations that will be responsible for educating health care providers about Covered California and how the exchange will operate come January 2014. CMA's application was submitted jointly with the Latino Physicians of California and the American Academy of Pediatrics.

Funding will largely be distributed to the counties for local education and outreach and to ethnic physician organizations across the state.

Covered California is expected to announce its awards later this month, while the grant period will run from September 2013 to December 2014.

Plan departures leave questions for California policy holders

While much attention has been given to the successful signing of health plans participating in Covered California’s new online insurance marketplace, it’s worth noting that some major players in the state’s current insurance market are refusing to play ball.

In June, both United Healthcare and Aetna announced that they would not be participating in California’s individual market following the end of 2013. In announcing their departures, both companies noted that only a small portion of their overall business was conducted in California, and given the coming changes promised through the Affordable Care Act (ACA), no longer found it viable to offer plans in the state. Both firm’s decisions apply to the state’s individual market as a whole, not simply the portion that would be served by the exchange.

United and Aetna currently make up 2 percent and 5 percent of the state’s individual market, respectively, together covering just shy of 60,000 Californians.

While some observers are using the departure of United and Aetna to condemn the ACA, claiming that the increased regulation of the market in California forced the insurers out of state, others are more curious about how the smaller, regional plans will help absorb the roughly 60,000 residents who previously purchased covered through the two soon-to-be-departed firms.

These plans, such as L.A. Care Health Plan, Valley Health Plan and Chinese Community Health plan are relatively unknown to the majority of Californians, but could play a large role in providing coverage to residents through the exchange beginning in 2014.

In other departure news, Anthem Blue Cross announced last month that it would not be participating in Covered California’s Small Business Health Options Program (SHOP), the exchange’s small group marketplace, for at least the first year.

Anthem’s decision to remain on the sidelines could potentially be a bigger issue than Aetna and United’s refusal to participate in the individual market. Recent estimates suggest that Anthem represents roughly a third of California’s small group market.

With plans selected to offer products on SHOP beginning in 2014, it will be interesting to see who is willing and able to take up such a massive market share left behind as a result of Anthem’s departure.

DHCS to implement 10 percent Medi-Cal cuts in January 2014

The Department of Health Care Services (DHCS) today announced that it would begin to implement the 10 percent Medi-Cal physician payment rate reduction on October 1, 2013, for Medi-Cal managed care and on January 9, 2014, for fee for service. DHCS also announced that it would be retroactively implementing the cuts for FFS providers to June 1, 2011, when the law authorizing the cuts went into effect.

DHCS said it will recoup a percentage of provider payments to recover overpaid funds during the retroactive period. These retroactive payment recoveries will not occur until after the prospective 10 percent payment reductions are implemented. Additional details were not provided, but assuming the retroactive period ends as of the date the prospective cuts begin, the entire portion for which there would be a "clawback" cut would be June 1, 2011, until January 9, 2014, or over 29 months.

Specialty physician services in Medi-Cal managed care will not be subject to a reduction. CMA is working with the state to obtain additional information.

In March of 2011, the California Legislature passed and Governor Jerry Brown signed AB 97, which included a 10 percent reimbursement rate cut for physicians, dentists, pharmacists and other Medi-Cal providers.

Shortly thereafter, the California Medical Association filed a lawsuit, CMA et al. v. Douglas et al., to stop the State of California from implementing the 10 percent cut included in the 2011-2012 state budget.

In January 2013, a three judge panel of the 9th Circuit Court of Appeals reversed a decision by a district court that found that the cuts would irreparably harm the millions of patients who rely on Medi-Cal for health care. The Ninth Circuit also vacated the preliminary injunction clearing the way for implementation of these rate reductions. CMA requested a rehearing from the full Ninth Circuit Court of Appeals, which was denied.

CMA and the other plaintiffs in the case (the California Hospital Association, California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response), subsequently filed a request with the U.S. Supreme Court for a stay to prevent the cuts going forward. This request was denied a day later.

These cuts could not come at a worse time, as California is poised to expand Medi-Cal to 1.4 million more Californians under federal health reform and the demand for physicians is expected to rise.

CMA is part of an unprecedented coalition of physicians, dentists, health care workers and hospitals that will continue working to stop the cuts. The coalition, called "We Care for California," includes the largest statewide organizations representing physicians, dentists, hospitals and health care workers, as well as health plans, first responders, caregivers and other health providers.

Even before the cuts, California's Medi-Cal provider payment rates are some of the lowest in the nation. Low reimbursement rates have driven many of California’s providers from the program. As a result, 56 percent of Medi-Cal patients report difficulty finding a doctor. If these cuts are not stopped, Medi-Cal will become nothing more than a broken promise of access to care.

Contact: Lishaun Francis, (916) 551-2554 or lfrancis@cmanet.org.

State delays duals pilot project until April 1

The California Department of Health Care Services (DHCS) announced today that it would delay by three months implementation of the state's "pilot project" to redesign care for Medicare/Medi-Cal dual eligibles. The program, called CalMediConnect, is now expected to begin no earlier than April 2014.

The project was authorized by the Assembly in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara.

Patients will be enrolled in a managed care plan unless they actively opt out.

The California Medical Association (CMA) had urged DHCS to withdraw the overly-ambitious project proposal and to take more time to develop a scaled-down project that gives seniors and the professionals that take care of them information and feedback mechanisms to assure continuity of care and improved care coordination. Unfortunately, the Centers for Medicare and Medicaid Services approved the project, clearing the state to begin implementation.

CMA will work with DHCS and other stakeholders to minimize the impact of the transition on physicians and their patients. CMA has also established this resource center to help physicians and their patients understand what is being implemented. There you will find:

• Basic information about what is being implemented
• Eligibility, enrollment and opt-out information
• Continuity of care provisions
• Financing and payment information
• Patient letters

For more information, visit www.cmanet.org/duals.