Health plans terminate relationship with Vantage Medical Group The California Medical Association (CMA) has learned that two health plans, the Inland Empire Health Plan (IEHP) and Molina Healthcare, are terminating their contracts with Vantage Medical Group. Two other plans, Blue Shield of California and Care1st Health Plan, have issued notices of material breach with an intent to terminate. The plans have filed requests with the California Department of Managed Health Care (DMHC) to transfer their enrollees to other delegated groups. According to IEHP’s block transfer filing with DMHC, Vantage engaged in conduct 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. The plan filings with DMHC indicate over 280,000 enrollees will be affected by the IEHP and Molina terminations as follows: Inland Empire Health Plan: Termination effective August 31, 2018, affecting 171,425 enrollees in Riverside County and 102,621 enrollees in San Bernardino County. Molina Healthcare: Termination effective August 31, 2018, affecting 7,413 enrollees. Blue Shield and Care1st issued notices of their intent to terminate, if Vantage fails to correct the breaches. If the breaches are not corrected to the payors’ satisfaction, another 6,000 enrollees will be affected as follows: Blue Shield of California: Termination effective August 31, 2018, affecting 2,979 enrollees. Care 1st Health Plan: Termination effective August 31, 2018, affecting 3,034 enrollees. CMA will provide additional information on the transitions as it becomes available. Physicians should be diligent in obtaining updated insurance information from patients and verifying 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 are 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, care of children between birth and 36 months, or for the performance of a surgery or other procedure that has been authorized, may qualify 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 On-Call document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.” CMA will provide more information on IEHP’s transition once we received updated information on the receiving groups. Practices that are experiencing problems with Vantage or issues resulting from the plan terminations are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. July 11, 2018 General, Managed Care, Medi-Cal Blue Shield, Commercial Payors, Department of Managed Health Care, DMHC, Payor Contracting 0 0 Comment Read More »
Blue Shield implements system fix for AB 72 claims Last year, the California Medical Association (CMA) worked with Blue Shield of California to correct two issues affecting accurate payment of claims subject to the state’s new out-of-network billing and payment law (AB 72). The issues were identified as being due to manual claim processing errors, because the payor had not yet updated its system to allow automated processing of claims subject to AB 72. Blue Shield recently announced it was implementing a system update on June 28, 2018, that will allow claims subject to AB 72 to be processed automatically. The payor reports it will conduct regular audits of these claims post-automation to ensure accuracy. Practices with additional questions or concerns can contact CMA’s Reimbursement Helpline at (800) 786-4262 or economicservices@cmanet.org. July 11, 2018 General, Managed Care AB 72, Blue Shield, Out of Network Care 0 0 Comment Read More »
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 »
Blue Shield updates fee schedule effective December 1 Blue Shield of California recently announced changes to its physician fee schedule that will take effect December 1, 2017. While the notice indicated that the new rates would be available on the Blue Shield website by October 1, CMA has learned that Blue Shield experienced technical difficulties that will delay the availability of the new rates on the website, until October 9, 2017 (tentatively). The rates will be located under "Helpful Resources," then “Professional Fee Schedule,” then click “Search the Claims Fee Schedule” using a “Date of Service” of December 1, 2017, or later. Physicians can also request a copy of the new fees for up to 20 codes by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Information and Enrollment Department at (800) 258-3091. Blue Shield will provide a response to your inquiry within 10 business days. As always, physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practices. To help physicians understand their rights when a health plan has sent notice of a material change to a contract, CMA has published "Contract Amendments: An Action Guide for Physicians," available in CMA's online resource library. The guide includes a discussion of options available to physicians when presented with a material contract change, as well as a financial impact worksheet that will help physicians calculate the net impact of fee schedule changes on their practice. October 13, 2017 Managed Care Blue Shield, Payor Contracting 0 0 Comment Read More »
Health plans begin transitioning patients from troubled Nivano The California Medical Association (CMA) has learned that two health plans—Blue Shield and UnitedHealthcare (UHC)—have recently terminated their delegated agreements with Nivano Physicians Medical Group and are in the process of transferring patients from Nivano to alternative networks. Nivano, also known as Northern California Physicians Medical Group with enrollees in Placer, Nevada, Sacramento, Yuba and Colusa counties, is currently on a corrective action plan with the Department of Managed Health Care (DMHC) for failure to meet financial solvency criteria. CMA has also received a surge of complaints about delays in authorizations and changes to Nivano policies and procedures over the past few months. Blue Shield filed a block transfer request with DMHC on July 5 initiating the transfer of its 2,707 covered lives from Nivano. About 1,900 patients are being transferred into a new HMO Direct Contract Network with Blue Shield of California. A notice regarding this change was sent to Blue Shield participating physicians on July 21. The remaining 796 patients will be distributed to Hill Physicians Medical Group (728), Sutter Independent Physicians (34) and UC Davis Medical Group (34). Blue Shield’s contract with Nivano will be terminated effective August 10, 2017, according to a recent notice sent to enrollees. UHC is also terminating its relationship with Nivano and is reassigning most of its 1,750 covered lives effective August 1, 2017. UHC is transferring 756 patients to Hill Physicians and 771 to direct UHC HMO provider contracts to allow patients to remain with their former Nivano physicians. In the situation where a provider is not contracted with either Hill Physicians or UHC directly, patients will be allowed to complete treatment through continuity of care arrangements. CMA is working closely with both Blue Shield and UnitedHealthcare to ensure claims that were authorized by Nivano, but performed after the termination dates, are still honored by the plans. Practices that are experiencing problems with Nivano or issues resulting from the plan terminations are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. August 9, 2017 Managed Care Blue Shield, UnitedHealthcare 0 0 Comment Read More »
Updated payor profiles for 2017 now available The California Medical Association’s (CMA) Center for Economic Services is publishing updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, and other key contacts. Don’t waste your time searching the internet for this information – members can download CMA’s Payor Profiles free of charge in the CMA Resource Library. August 1, 2017 CMA, Managed Care, Medi-Cal, Medicare Aetna, Anthem Blue Cross, Blue Shield, Cigna, Health Net, Insurance, Medi-Cal, Medicare, Noridian, Payor, Payor Profiles, Running a Practice, UnitedHealthcare 0 0 Comment Read More »
Blue Shield to update fee schedule effective December 1 Blue Shield recently announced changes to its physician fee schedule that will take effect December 1, 2016. The new rates are now available on the Blue Shield website (under "Helpful Resources," click “Professional Fee Schedule” then click “Search the Claims Fee Schedule”). To view the new fees, change the default date of service on the “Search Fee Schedule” page to December 1, 2016, (effective date of the change) or later. Physicians can also request a copy of the new fees for up to 20 codes by completing the allowance review form enclosed with the notice, or by calling the Blue Shield Provider Information and Enrollment Department at (800) 258-3091. Blue Shield will provide a response to your inquiry within 10 business days. As always, physicians are encouraged to carefully review all proposed amendments to health plan or medical group/IPA contracts. The California Medical Association (CMA) reminds physicians that they do not have to accept substandard contracts that are not beneficial to their practice. To help physicians understand their rights when a health plan has sent notice of a material change to a contract, CMA has published "Contract Amendments: An Action Guide for Physicians," available in CMA's online resource library. The guide includes a discussion of options available to physicians when presented with a material contract change, as well as a financial impact worksheet that will help physicians calculate the net impact of fee schedule changes on their practice. October 13, 2016 General, Managed Care Blue Shield 0 0 Comment Read More »
Physicians encouraged to verify CHPI data by November 11 Earlier this month, approximately 13,000 physicians in California received their individual quality measurement scores for the second cycle of the California Healthcare Performance Initiative System (CHPI) quality rating program. Physicians can review and verify the accuracy of the data used to calculate their scores through the CHPI online portal through November 11, 2016. The program rates physicians using claims data from Medicare fee-for-service, Anthem Blue Cross, Blue Shield of California and United Healthcare. This claims data includes both commercial and self-funded health plan data from HMO, PPO, POS and Medicare Advantage products. The individual quality measurement scores were based on claims data for patient care provided January 1, 2012, through December 31, 2014. Physicians were assigned a star rating of one to four stars, based on where they fall as a percentile within a “peer group,” for each measure, as well as a composite score. Physicians who wish to verify the accuracy of the data used to calculate their scores can do so through the CHPI Review and Corrections portal. To access the review and correction portal, physicians will have to register using their username and registration token – both listed at the top left of each page of the report. Once registered, you will receive a confirmation email with instructions to create a password. According to CHPI, it will treat the data as complete and accurate if no corrections are made. This means that even if a physician has not logged into the online portal during the review and correction period, CHPI will still publish the physician's data. Physicians who review their data and identify errors have until November 11, 2016, to report any discrepancies via the CHPI online portal. At the close of the physician review and correction period, discrepancies will be evaluated and corrected, with the results recalculated prior to the public release of the ratings. After November 11, the review and correction period will close, and physicians will be unable to review or report discrepancies. CHPI has advised the California Medical Association (CMA) that in addition to publishing the ratings publicly, it will also release an aggregated data file to the aforementioned participating plans following the review and correction period later this year. CMA inquired as to how the data would be utilized by the plans, but as of the time of publication, it was not known. For more information on the CHPI rating methodology, visit the CHPI website at www.chpis.org. CHPI has also published an FAQ on its rating program and a step-by-step review and corrections tutorial. Physicians who did not receive a letter but would like to confirm whether they are included in CHPI’s rating results can use the CHPI physician lookup at https://provider.medinsight.milliman.com/clients/CHPI/Public/Lookup. If you have questions or concerns about the CHPI rating results, you may email chpicorrections@pbgh.org and you should receive a response within 48 hours. Physicians who do not hear back within 48 hours or who identify a high volume of discrepancies in the data used to calculate their scores are encouraged to contact CMA at (916) 551-2061 or jwilliams2@cmanet.org. CMA will also be hosting a webinar on October 5 where CHPI staff will provide an overview of the quality rating project, along with step-by-step instructions on how physicians can review their data for accuracy before the quality scores are published. The webinar is free to CMA members ($99 for non-members). To register, visit the CMA website at www.cmanet.org/events. September 22, 2016 Managed Care, Medicare Medicare, Quality of Care, United Healthcare, Anthem Blue Cross, Blue Shield, CHPI 0 0 Comment Read More »
Blue Shield to shut down for four days in September Last week, Blue Shield of California announced that it would close its doors for the four days after Labor Day to reduce its payroll-related liabilities, citing losses in the Covered California health insurance exchange. The shutdown, lasting from September 5 to 9, will affect most of its 6,000 employees. The company claims this will save it an estimated $4 million. Some Blue Shield customer service representatives and medical services staff are still expected to be on the job during that period. The California Medical Association has also confirmed that while the Blue Shield Provider Relations department will be closed, the following departments will remain open: Provider Customer Service, Provider Information and Enrollment, Claims Processing, and Grievances and Appeals. If practices have urgent prescription and/or procedure authorization requests during, they can call Blue Shield’s Medical Care Solution line at (800) 541-6652 for assistance. According to the payor, this and all other critical customer facing departments will be staffed during the closure. The shutdown will not affect about 1,000 employees who work for Care1st, which Blue Shield acquired last fall, and some staffers in customer service and related areas who will remain on the job. Blue Shield raised its Covered California rates by nearly 20 percent for 2017, citing the high costs of covering enrollees. The payor said it drastically underpriced premiums for the state's exchange. The insurer also plans to cut 460 jobs in Sacramento and the Central Valley. Last month UnitedHealth Group, Humana and Aetna said they would exit most Affordable Care Act markets, citing revenue losses. August 25, 2016 Managed Care Blue Shield 0 0 Comment Read More »
Blue Shield implements system fix to correctly pay HPV9 claims Under the Affordable Care Act, health plans are required to provide “first dollar” coverage for preventive services. This means that the plan cannot apply patient cost sharing, such as copays, coinsurance or deductibles, to these services. However, in September 2015, the California Medical Association (CMA) was alerted by a physician practice that Blue Shield of California was applying patient cost sharing when it processed HPV9 claims with CPT code 90651. CMA escalated the issue to Blue Shield and has been working with the payor since then to correct the issue. Blue Shield confirmed it implemented a system fix on May 18, 2016. The payor also confirmed it identified over 14,500 claims dating back to January 1, 2015, that were reprocessed to pay correctly. The reprocessing project was completed at the end of June 2016. Physicians are encouraged to review their records to ensure all affected claims were reprocessed correctly and to contact Blue Shield if they identify any that are still outstanding. August 9, 2016 Managed Care Affordable Care Act, Blue Shield, ACA 0 0 Comment Read More »
