Payors report system changes to comply with AB 72 When California’s new out-of-network billing and payment law (AB 72) took effect on July 1, 2017, the California Medical Association (CMA) began receiving calls from physician offices concerned that Anthem Blue Cross and Blue Shield of California were not correctly paying claims. In both cases the incorrect payments were linked to manual processing of AB 72 claims. CMA worked with Blue Shield to ensure affected claims through October of 2017 were automatically reprocessed. Blue Shield also committed to conducting weekly audits to catch any additional claims that were processed erroneously. While the payor continues to process claims manually, Blue Shield reports it is working on an automated system fix expected to be implemented by mid-year. Anthem has also reported to the Department of Managed Health Care that it implemented a system fix to allow claims subject to AB 72 to be processed automatically rather than manually. AB 72 requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for covered, non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges. The interim rate is defined as the greater of the average contracted rate or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered. The new law also requires payors to honor assignment of benefits and issue the interim payment directly to physicians. If your practice has received incorrect payments or denied claims related to the new law, CMA wants to hear from you. Practices can contact CMA’s AB 72 advocate Juli Reavis at (888) 401-5911 or jreavis@cmanet.org. To learn more about this law, find out if payors are reimbursing you correctly and learn how to dispute the interim rate, visit CMA’s AB 72 Resource Center. April 5, 2018 General, Managed Care Anthem Blue Cross, Blue Shield, Economic Advocacy, AB 72, Out of Network Care 0 0 Comment Read More »
New Anthem anesthesia policy can have blinding consequences A policy change made by health insurer Anthem, Inc. could result in increased risk for many patients – up to and including blindness – if not immediately rescinded, according to physicians’ groups. The California Academy of Eye Physicians and Surgeons (CAEPS) and the California Society of Anesthesiologists (CSA) have sent letters to Anthem Inc. requesting that they immediately rescind a new policy that deems Monitored Anesthesia Care (MAC) “not medically necessary” during “routine” cataract surgery – a move seen as endangering patients. These were followed up with complaints to the California Department of Managed Health Care (DMHC) and the California Department of Insurance by the California Medical Association (CMA), and supported by the other groups. “The surgery is carried out in a tiny space about a third of the size of a thimble using a needle vibrating at ultrasonic speeds that can cause blindness if it contacts the wrong structures,” wrote Craig H. Kliger, MD, an ophthalmologist, and CAEPS Executive Vice President in a letter to Anthem. “Sedation is frequently vital to allow the patient to relax and avoid movement that could be catastrophic, thus minimizing risk.” “The policies around cataract surgery are vital to patient safety,” said David H. Aizuss, MD, an ophthalmologist and President-Elect of the CMA. "Anthem's newest policy change falls below the standard of care, and it follows a disturbing pattern of putting patients at risk to make a profit." Anthem appears to cherry-pick statements in the “Anesthesia” section of an American Academy of Ophthalmology (AAO) Preferred Practice Pattern on the issue to justify its move. “Unfortunately, we believe Anthem is misinterpreting that document, and that proper interpretation would lead to the opposite conclusion,” wrote Dr. Kliger in the letter, meaning that sedation and concurrent appropriate monitoring should instead be considered necessary for the safety of the patient. “If Anthem restricts payment for MAC services, thousands of patients either will have to pay for the service themselves or will have to undergo surgery under suboptimal conditions. This guideline seems especially harsh toward fragile elderly patients, many of whom have other coexisting illnesses that complicate the use of sedation,” wrote Karen S. Sibert, MD, FASA, a physician anesthesiologist and CSA President, in CSA’s letter to the insurer. Although Anthem amended the policy on February 1st to clarify that it did not intend to exclude “moderate sedation” from coverage, such sedation would have to be managed by the surgeon, which the AAO document explicitly says should not happen for cataract surgery because the procedure is very precise work, making it risky to divide time between the two tasks. Therefore, a qualified anesthesia provider would be both required and requested in all situations when sedation is anticipated to be needed (the vast majority of current cataract surgery cases), making the activity “monitored anesthesia care,” which the policy still excludes except under extreme exceptions. “Anthem's predatory practices and policies are increasing in intensity, frequency and with complete disregard for their impact on California's health care delivery system," said Theodore Mazer, MD, President of the CMA. “We urge the DMHC and the Department of Insurance to intervene when insurers functionally block access to services that are widely viewed as the standard of care." The full content of the policy, letters, and complaints can be found by using the following links: Anthem Policy CG-MED-60 (published 12/27/17) Anthem Policy CG-MED-60 (published 2/1/18) (Note the revisions do not address the concerns) CAEPS Letter to Anthem CSA Letter to Anthem CMA Complaint to the California Department of Managed Health Care CMA Complaint to the California Department of Insurance # # # The California Medical Association represents the state’s physicians with more than 43,000 members in all modes of practice and specialties. CMA is dedicated to the health of all patients in California. For more information, please visit CMAnet.org, and follow CMA on Facebook, Twitter, LinkedIn and Instagram. The California Academy of Eye Physicians and Surgeons is the only statewide organization representing California ophthalmologists and their patients. CAEPS' activities include public education about important eye health care concerns, legislative advocacy, interaction with third party payers about reimbursement and coverage issues, and continuing medical education for ophthalmologists and their staffs. For more information, please visit www.caeps.org. The California Society of Anesthesiologists is a physician organization dedicated to promoting the highest standards of the profession of anesthesiology, to fostering excellence through continuing medical education, and to serving as an advocate for anesthesiologists and their patients. For more information, please visit www.csahq.org. February 5, 2018 General, Managed Care Advocacy, Anesthesiology, Anthem Blue Cross, California Academy of Eye Physicians and Surgeons, California Society of Anesthesiologists, Ophthalmology 0 0 Comment Read More »
CMA calls for investigation into Anthem policy restricting use of sedation during cataract surgery On December 27, 2017, Anthem Blue Cross implemented a clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. The California Medical Association (CMA) believes this drastic change in policy will cause significant patient safety concerns and put patients at risk of serious complications, including blindness. The new policy, “Anesthesia for Cataract Surgery,” deems intravenous anesthesia (including moderate sedation, monitored anesthesia care or general anesthesia) not medically necessary, except in very narrow circumstances. Anthem patients wishing to have any form of intravenous anesthesia during the procedure will now be forced to pay out of pocket. In addition to the patient safety issue, CMA is also concerned about the legality of this new policy, as it is inconsistent with California law that requires health plans to prove that medical decisions are rendered by qualified medical providers, unhindered by fiscal and administrative management (Health & Safety Code §1367(g)). The policy also conflicts with Anthem’s obligations under to cover essential health benefits (Health & Safety Code §1367.005(a)). CMA is further concerned that Anthem failed to properly notify contracted physicians of this material change, as required by state law (Health & Safety Code §1375.7(b)(1)(B)). CMA has asked the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) to investigate and require Anthem to rescind the policy retroactive to the effective date. Both the California Academy of Eye Physicians and Surgeons and the California Society of Anesthesiologists recently expressed similar patient safety concerns with the policy in letters to Anthem and asked the plan to urgently rescind the policy. What actions can physicians take? Anesthesiologists who have received a medical necessity denial for IV sedation during cataract surgery since the implementation of the policy may wish to help their patient file an independent medical review (IMR) with the regulator. Physicians can also file an IMR on behalf of their patient if the patient authorizes the physician to do so. For DMHC-regulated products, in order for the physician to file on the patient’s behalf, the patient must complete the “Authorized Assistant Form.” To file for IMR, visit the DMHC’s IMR webpage. For CDI-regulated products, in order for the physician to file on the patient’s behalf, the patient must complete the “Authorization for release of medical records and designation of independent medical review agent” form (see page three). To file for IMR, visit the CDI’s IMR webpage. For more information on Independent Medical Reviews, see CMA’s On-Call Document #7155, "Independent External Medical Review." If a physician determines that a patient requires IV sedation for a cataract surgery, CMA recommends the doctor review his/her contract to understand any patient billing restrictions. Many contracts prohibit physicians from collecting directly from patients for services deemed not medically necessary unless the patient signs the “Covered Individual Patient Responsibility Agreement – Waiver Letter” prior to the procedure. If your practice and patients are affected by this policy change, are receiving medical necessity denials for anesthesia services for cataract surgery since the effective date, or your practice did not receive the required advance notice of the change, please contact CMA at (888) 401-5911 or economicservices@cmanet.org. February 5, 2018 General, Managed Care Anthem Blue Cross, Anesthesiology, Contract Amendment, Medical Necessity, Opthalmology 0 0 Comment Read More »
Anthem dials back modifier 25 payment reduction policy; delays implementation This past fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. The California Medical Association (CMA) quickly jumped into action and coordinated with the American Medical Association (AMA) and the American Association of Dermatologists, along with many other state and specialty organizations, to push back on the proposed change. Due to the overwhelming opposition from organized medicine, Anthem recently announced it would reduce the magnitude of its modifier 25 payment cut from 50 percent to 25 percent, and would delay implementation until March 1, 2018. Anthem will be issuing formal guidance to network physicians communicating these changes within the coming weeks. While this is an improvement on Anthem’s original planned policy, CMA and AMA still strongly oppose this unjustified major reduction in physician payment. CMA will continue to work with AMA and others to seek full retraction of the Anthem policy. CMA has also raised this issue with the California Department of Managed Health Care. In the meantime, physicians are urged to thoroughly review and assess the impact any proposed contract modifications would have on their individual practices. Physicians should also be aware that California law requires health plans and their contracting medical groups/IPAs to provide 45 business days’ advance notice of a material change to a contract, manual, policy or procedure. A change is considered “material” if “a reasonable person would attach importance [to it] in determining the action to be taken upon the provision.” Physicians have the right to terminate an agreement prior to the implementation of a proposed material change. For more information on physicians’ rights and options when a health plan makes a material change to a contract, manual, policy or procedure, see “Contract Amendments: An Action Guide for Physicians.” This resource is available free to CMA members. January 29, 2018 General, Managed Care Contract Amendment, Economic Advocacy, Payor Contracting, Anthem Blue Cross 0 0 Comment Read More »
Anthem still not complying with AB 72 interim payment rules, physicians report The California Medical Association (CMA) has continued to receive reports from physician offices that Anthem Blue Cross is not paying the “interim payment” as required under California’s new law (AB 72) limiting out-of-network billing for covered, non-emergent services performed at in-network facilities. CMA has also received reports that Anthem representatives have advised some physicians that its Covered California EPO products are not subject to AB 72, which is incorrect. The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges. The interim rate defined in AB 72 is the greater of the average contracted rate (including only commercial contracts) or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered. If your practice has received incorrect payments or denied claims from Anthem or any other payor related to the new law, CMA wants to hear from you. Practices can contact CMA at (888) 401-5911 or economicservices@cmanet.org. For more information, visit www.cmanet.org/ab-72. December 28, 2017 Managed Care Anthem Blue Cross, AB 72, Economic Advocacy, Out of Network Care 0 0 Comment Read More »
Anthem Blue Cross to implement restrictive outpatient advanced radiology policy Effective December 1, 2017, Anthem Blue Cross will implement a new policy restricting outpatient advanced radiologic imaging procedures in the hospital setting. The updated policy, originally scheduled to become effective October 1 but recently delayed, indicates that advanced radiologic imaging procedures in the hospital outpatient department are only considered medically necessary under the follow circumstances: If services are only available in the hospital setting; or The patient requires obstetrical observation; or The patient is receiving perinatology services; or There are no other geographically accessible appropriate alternative sites to perform the service, including in instances where: general anesthesia or moderate or deep sedation is required and unavailable at a freestanding facility; or patient size prohibits the use of equipment at a freestanding facility; or the patient has documented history of claustrophobia. Anthem will utilize AIM Specialty Health to administer the clinical appropriateness reviews for all advanced imaging services, including making the determination if an imaging service requires a hospital-based outpatient setting or if a free-standing imaging center will be chosen to perform the service. The California Medical Association is in the process of evaluating the new policy to better understand how it would affect physician practices and patient care. Additional information and instructions regarding this program can be found at aimproviders.com/radiology. October 19, 2017 General, Managed Care Anthem Blue Cross, Radiology 0 0 Comment Read More »
Anthem Blue Cross offering fall seminars on 2017 operational updates Throughout October, the Anthem Blue Cross Provider Network Education Team will offer live seminars to discuss 2017 operational updates. Topics will include participation in the California health care marketplace, Blue Cross and Blue Shield alpha prefix change, and details on the new website for radiology services. Each seminar runs from 8:30 a.m. to 12 p.m. The first session is slated for October 3 in San Mateo, and the series will conclude on October 26 in Fresno. Practices interested in attending should register on the Anthem website. Click here for the complete list of dates. September 25, 2017 Managed Care Anthem Blue Cross, Seminars 0 0 Comment Read More »
Physicians report Anthem not complying with AB 72 interim payment rules The California Medical Association (CMA) has received reports from physician offices that Anthem Blue Cross is not paying the “interim payment” as required under the recently effective law (AB 72) limiting out-of-network billing for covered, non-emergent services performed at an in-network facility. The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges. The interim rate defined in AB 72 is the greater of the average contracted rate (including only commercial contracts) or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered. If your practice has received an incorrect payment from Anthem or any other payor related to the new law, CMA wants to hear from you. Practices can contact CMA at (888) 401-5911 or via email at economicservices@cmanet.org. For more information, visit www.cmanet.org/ab-72. September 25, 2017 General, Managed Care AB 72, Anthem Blue Cross, Out of Network Care 0 0 Comment Read More »
Anthem Blue Cross rescinds termination of Medicare Advantage agreement with Brown and Toland Anthem Blue Cross has reached an agreement to extend its Medicare Advantage contract with Brown & Toland Physicians. Although Anthem Blue Cross previously announced the contract would be terminated effective October 1, 2017, the parties have since signed a contract extension through December 2018. The termination would have affected approximately 1,900 Medicare Advantage enrollees in San Francisco. Click here to see the letter sent from Brown & Toland. Physicians with questions can contact Brown & Toland Physician Services at physicianservices@btmg.com. August 17, 2017 Managed Care, Medicare Anthem Blue Cross, Medicare Advantage, San Francisco Medical Society 0 0 Comment Read More »
Anthem Blue Cross terminates Medicare Advantage agreement with Brown and Toland Effective October 1, 2017, Anthem Blue Cross will terminate its contract with Brown & Toland Physicians for its Medicare Advantage product. The termination will affect approximately 1,900 Medicare Advantage enrollees in San Francisco. Affected patients will be reassigned to Asian American Medical Group, Jade Health Care Medical Group or Imperial Health Holdings Medical Group. The termination was reportedly due to a failure to reach a contractual agreement with Brown & Toland. Physicians with questions can contact Brown & Toland representative Stephanie Mamane at (415) 972-4282 or smamane@btmg.com. August 9, 2017 Managed Care, Medicare Anthem Blue Cross, Medicare Advantage, San Francisco Medical Society 0 0 Comment Read More »
