Anthem Blue Cross to review level 5 emergency room claims Anthem Blue Cross announced in its December Professional Network Update that, beginning January 1, 2016, it will initiate a pre-payment review of level 5 emergency department visits billed with CPT 99285 or G0384. Anthem has advised CMA that it will focus on level 5 emergency department visits that are billed in combination with diagnosis codes that “are an unlikely combination for high level visits.” The payor will exclude claims billed with critical care, observation or inpatient admissions. Claims with CPT codes 99285 and G0384 that are selected by Anthem for pre-payment review will be pended and, if records are not included with the claim, a request for medical records will be generated. Anthem will review the records to verify that the documentation supports the level of service billed per CPT guidelines. Anthem has advised CMA that if it does not believe, after review of the records, that the documentation supports the level billed, it will pay the claim based on the evaluation and management (E/M) level supported. The explanation code will reflect this action. Providers will have the ability to dispute the findings through the normal provider dispute resolution process. February 3, 2016 General Emergency Departments, Emergency Rooms, Emergency Services, Anthem Blue Cross 0 0 Comment Read More »
Survey: ER visits continue to climb under Affordable Care Act A recent survey conducted by the American College of Emergency Physicians (ACEP) shows that emergency room (ER) visits are continuing to climb since the implementation of the Affordable Care Act (ACA), despite predictions that the law would result in less crowding. According to a news release, about three-quarters of the 2,098 ER physicians surveyed said that visits have risen since January 2014 — a significant increase from a year earlier, when less than half said they saw an upturn. More than one-quarter reported “significant increases in all emergency patients” since health insurance mandates took effect, and more than half said there has been a boost in Medicaid patients in the ER. The new figures go against what many ACA supporters initially theorized, which was that better access to health care providers would result in a drop in ER visits. “There was a grand theory the law would reduce ER visits,” ACEP spokesman Howard Mell, M.D., told The Wall Street Journal. “Well, guess what, it hasn’t happened. Visits are going up despite the ACA, and in a lot of cases because of it.” According to ACEP, hospital and emergency department closures in certain areas may be one reason for the increase in volume, as well as Medicaid recipients turning to ERs when they can’t receive care in a timely manner or find a physician to accept their coverage. Citing a new Health Policy Alternatives report, ACEP noted that more than half of providers listed by Medicaid managed-care plans could not offer appointments to enrollees, and that the median wait time for an appointment for Medicaid patients was two weeks. “America has severe primary care physician shortages, and many physicians will not accept Medicaid patients because Medicaid pays so inadequately,” said ACEP President Michael Gerardi, M.D., in a statement. “Just because people have health insurance does not mean they have access to timely medical care.” The ACEP survey also showed the illnesses and injuries of ER patients becoming more serious. About 44 percent of respondents reported the severity of illness or injury among emergency patients has increased, and about 42 percent said it has remained the same. The survey was conducted online from March 16-23. For complete poll results, click here. May 15, 2015 General, Managed Care Affordable Care Act, Emergency Rooms, Health Care Reform, ACA 0 0 Comment Read More »
Study finds that ACA Medi-Cal expansion could fuel ER use A retrospective study conducted by researchers at the University of California, San Francisco (UCSF) found that the number of visits to California emergency rooms (ERs) rose by 13.2 percent between 2005 and 2010, from 5.4 million to 6.1 million annually, with a significant 35 percent increase in the number of ER patients insured through Medi-Cal. The authors suggest that the Medi-Cal expansion under the Affordable Care Act (ACA) could further increase these numbers, as millions of additional patients become eligible for Medi-Cal in 2014. Researchers also found that Medi-Cal patients had the highest ER usage burden for ambulatory-care-sensitive conditions (54.76 per 1,000 patients on average) compared with those who had private insurance (10.93 per 1,000 patients) or no insurance at all (16.6 per 1,000 patients). This study comes on top of the announcement this month that the California Department of Health Services intends to begin to implement a 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. This reduction is the result of legislation that was passed in March of 2011, when California’s budget was in dire straits. Even though California's fiscal outlook is much brighter now than it was in 2011 when the legislature first passed the 10 percent cut, the state has moved forward with the cuts and will retroactively collect payment back to July 2011. The cuts had been held up in court while the California Medical Association (CMA) pursued legal action to stop the state from decimating California's already tattered safety net. Unfortunately, the Ninth Circuit Court of Appeals recently overturned the injunction, clearing the way for the state to begin implementation. CMA has submitted a petition to the U.S. Supreme Court, asking them to review the case. (See, "CMA files a petition with the Supreme Court to block the 10 percent physician reimbursement cut" for more information.) These cuts will assuredly force physicians out the Medi-Cal program, which is expected to assume care for more than 2 million new patients in 2014 under the ACA Medicaid expansion. Even before the cuts, California's Medi-Cal provider payment rates were 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. When they are unable to find a provider, many Medi-Cal patients seek preventive and other non-urgent care in hospital ERs. Others may simply go without preventive and primary care altogether and end up in the ER only after their condition has become severe. The inability to find a provider adds to pervasive ER overcrowding, which increases wait times, decreases quality and threatens access to emergency care for everyone. If these cuts are not stopped, Medi-Cal will become nothing more than a broken promise of access to care. The UCSF study was supported by the California HealthCare Foundation, the National Center for Advancing Translational Sciences, the National Institutes of Health and the Robert Wood Johnson Foundation Physician Faculty Scholars Program. View the research letter, recently published in the Journal of the American Medical Association. September 20, 2013 Medi-Cal Emergency Physicians, Emergency Rooms, Insurance/Reimbursement, Medi-Cal, Medi-Cal Cuts, Access to Care 0 0 Comment Read More »
Physicians urged to call Gov. Brown and ask him to sign the Maddy EMS Fund bill The California Medical Association (CMA) and the American College of Emergency Physicians (ACEP) are cosponsoring a bill that will extend funding for the Maddy Emergency Medical Services (EMS) Fund. Without this bill (SB 191/Padilla), providers of emergency medical care throughout the state will lose $50 million per year that is currently used to offset the costs incurred for care provided to uninsured patients in hospital emergency rooms (ER). Without this bill, the law that authorizes the Maddy Fund is set to expire on January 1, 2014. Although the bill is expected to pass through the Legislature and head to the Governor’s desk soon, there is some concern that Gov. Brown could veto the bill. The Maddy Fund was established over 20 years ago as a means of providing critical resources for the delivery of emergency medical care to the uninsured. The funds are managed at the county level, with funding generated through the assessment of an additional penalty of $2 for every $10 collected in fines, penalties and forfeitures for criminal offenses. Emergency room physicians who treat uninsured patients who are unable to pay for their care can submit a claim to their county Maddy Fund for partial reimbursement. While the bill enjoys overwhelming support in the Legislature, the governor has already made clear his dislike for penalty fee assessments to pay for programs he feels should be paid by the taxpayers in general. The bill is expected to arrive on the Governor’s desk around August 16, 2013. Tell the Governor to sign this critical bill by calling, emailing and tweeting the Governor. He has until August 28 to sign it into law. To contact the Governor: Phone: (916) 445-2841 Email: http://govnews.ca.gov/gov39mail/mail.php Twitter: @JerryBrownGov (Tweets should include #SaveTheMaddyFund, #SignSB191, or #SB191 so that we can track if the hashtags are trending.) For more information, including sample letter and talking points, see CMA's grassroots action center. August 8, 2013 General EMS/MADDY Funds, Access to Care, Advocacy, Emergency Rooms 0 0 Comment Read More »
