Health plans terminate contracts with EHS and transition patients to other entities As previously reported, the California Department of Managed Health Care (DMHC) issued a cease-and-desist order on December 26, 2017, requiring nine health plans to terminate their contracts with Employee Health Systems (EHS) Medical Group Inc. This order comes after SynerMed—a company closely affiliated with EHS—was accused of blocking patient access to specialists to hold down costs. EHS has 600,000 patients statewide—90 percent of whom are Medi-Cal managed care patients. As required by DMHC, health plans affected by this order were required to submit a transition plan by January 3, 2018, and have begun the transfer all EHS patients to different health care providers, due to be completed by February 5, 2018. EHS reports to the California Medical Association (CMA) that provider capitation checks for January have been issued and all fee-for-service payments to physicians will continue uninterrupted through the end of January. Additionally, the health plans have representatives onsite at SynerMed to ensure the timely exchange of authorization data and that enrollee and physician inquiries are being addressed appropriately. Other groups affected by the health plan terminations are Multicultural Medical Group, a San Diego based independent medical association acquired by EHS in late 2017, and Inland Valleys IPA, acquired by EHS in 2009. CMA is working with the health plans to ensure claims for services that were authorized by EHS, Inland Valleys IPA and Multicultural Medical Group, but performed after the termination dates, are still honored by the plans. CMA has also requested enrollee transfer documents through a public records request. 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.” Practices experiencing problems with EHS, Inland Valleys IPA or Multicultural are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. February 5, 2018 Managed Care, Medi-Cal Continuity of Care, Department of Managed Health Care, DMHC, Health Plans, Insurance, Medi-Cal, Payor Contracting 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 »
AMA urges quick action to stabilize individual insurance market With the window quickly closing to properly price individual insurance products for 2018, the American Medical Association (AMA) is urging President Trump and Congressional leaders to commit to continued funding for the cost-sharing reductions that are critical to stabilizing the individual market. AMA, along with other groups representing insurers, hospitals, health plan purchasers and physicians, sent a letter urging quick action to deliver short-term stability and affordable coverage while broader marketplace stabilization efforts are developed. Nearly 60 percent of all individuals who purchase coverage via the exchange receive financial assistance to make health care affordable. These subsidies reduce out-of-pocket costs for patients who might otherwise be unable to afford health care services despite being insured. The funding helps those who need it the most access quality care: low- and middle-income consumers earning less than 250 percent of the federal poverty level. If the cost-sharing subsidies are not funded, Americans will be dramatically impacted: Choices for consumers will be more limited, leaving individuals with fewer coverage options. Premiums for 2018 and beyond will go up by at least 15 percent, both on and off the exchange. Higher premium rates could drive out of the market those middle-income individuals who are not eligible for tax credits. If more people are uninsured, providers will experience more uncompensated care, which will further strain their ability to meet the needs of their communities and will raise costs for everyone, including employers who sponsor group health plans for their employees. Hardworking taxpayers will pay more, as premiums grow and tax credits for low-income families increase. The California Medical Association shares the sentiments of the letter and looks forward to working with Congress and the Trump Administration to take positive actions to stabilize the health care marketplace. April 19, 2017 General, Managed Care ACA, Affordable Care Act, AMA, American Medical Association, Health Insurance Exchange, Insurance 0 0 Comment Read More »
Anthem-Cigna mega-merger compromises health care access, quality and affordability Today, the U.S. Department of Justice (DOJ) and a bipartisan group of state attorneys started court proceedings to block the $48 million mega-merger between Anthem and Cigna (U.S. v. Anthem Inc., 16-cv-1493). “The California Medical Association has opposed the Anthem-Cigna mega-merger since day one because it will hurt patients and increase health care costs,” said California Medical Association (CMA) President Ruth E. Haskins, M.D. “Limiting market competition would compel insurers to contract with fewer physicians, resulting in higher premiums and longer wait times for referrals – not to mention forcing many patients to pay more to see out-of-network doctors.” Seventy-one percent of the nation’s metropolitan areas already lack competitive commercial health insurance markets. A merger between Anthem-Cigna would further diminish competition in 121 metro areas throughout the 14 states where Anthem is licensed to provide commercial coverage. “When it comes to scope, coverage and quality of health care, what do you trust – the clinical judgment of trained physicians or the corporate policy of insurance companies?” asked Dr. Haskins. “California’s health insurance markets need more competition to ensure that patients receive quality and affordable care.” In March 2016, a CMA-backed survey of California physicians revealed an overwhelming 85 percent opposed the Anthem-Cigna merger. Out of the 989 physicians surveyed from practices across the state, the majority expressed that the health insurer union could narrow physician networks (82 percent), force physicians to provide fewer services (90 percent) and pressure physicians into refraining from aggressive patient advocacy (75 percent). The DOJ’s lawsuit is supported by 11 states – including California, New York and Connecticut – and the District of Columbia. TWEET THIS NEWS “#AnthemCigna mega-merger compromises health care access, quality and affordability.” @CMAphysicians http://cal.md/2fLEEWN “Re: #HealthCare, who do you trust? Docs' clinical judgment or corp policy of insurance companies?” @CMAphysicians http://cal.md/2fLEEWN 85 percent of @CMAphysicians oppose the #AnthemCigna mega-merger because it’s bad for California patients. http://cal.md/2fLEEWN # # # 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 and YouTube. November 22, 2016 Managed Care Anthem Blue Cross, Cigna, Insurance, Legal Advocacy 0 0 Comment Read More »
Health plan group pilots program to improve physician directories America's Health Insurance Plans (AHIP) is launching a pilot program to ensure that physician directories are more accurate and up-to-date, the organization announced last week. The pilot program involves two directory vendors, BetterDoctor and Availity, and will include providers in three states: California, Florida and Indiana. The pilot program will run from April to September, according to AHIP, and will include the following eight California plans: Anthem Blue Cross Blue Shield of California Health Net of California Humana LA Care Molina Healthcare of California SCAN Health Plan Western Health Advantage As part of the pilot program, BetterDoctor will be reaching out to provider offices that are contracted with any of the eight plans via phone, fax and email to confirm physician and practice demographic information. The pilot will also help to ensure health plan and provider compliance with SB 137 requirements, which take effect July 1, 2016. The new law requires plans and insurers to comply with uniform standards and provide timely updates to their provider directories. The law includes multiple components aimed at providing patients with more accurate and complete information so they can identify which providers are in their payors' networks. It’s important that practices respond in a timely manner to the verification requests, as the new law not only requires payors to maintain accurate and current directories, but it also requires physicians to do their part in keeping the information up-to-date. Failure of practices to comply with the new requirements may result in payment delays, removal from directories and even contract termination. The new requirements underscore the importance of ensuring that practice demographic information, including whether or not the practice is accepting new patients, is up-to-date with contracted payors and any changes to practice demographics are communicated to the plan/insurer in a timely manner. (For more specifics about the provider requirements under SB 137, click here.) The pilot program will also help to alleviate the administrative burden on practices by reducing the number of plans individually reaching out to providers to verify practice information. AHIP said that the six-month pilot would take cooperation from both providers and health plans to make the program work. At the end of the pilot, AHIP will conduct an independent evaluation using feedback from providers, health plans and consumers, and will then develop best practices. AHIP is funding the project. The California Medical Association will be hosting a webinar on the topic with AHIP and its California vendor, BetterDoctor, on Wednesday, April 27. The webinar will cover an overview of the pilot program and the requirements of SB 137, including its effect on physician practices, as well as what to expect in terms of outreach and the information requested by the vendor. To register, click here. April 4, 2016 Managed Care Insurance, Medical Provider Networks, Provider Networks, Health Plans 0 0 Comment Read More »
Gallup poll says rates of uninsured continue to drop in most states According to a Gallup poll released Monday, the national uninsured rate has fallen to 11.7 percent, down from 17.3 percent in 2013. The poll shows that states that have expanded Medicaid under the Affordable Care Act – and have at least helped in the running of their health insurance marketplaces, rather than leaving it entirely to the federal government – have seen larger drops in uninsured rates. In the 22 states that took both of those measures, including California, the uninsured rate dropped to an average of 7.1 percent. California's uninsured rate dropped to 9.8 percent, down from 21.6 percent in 2013. In the 28 states that did not expand Medicaid or help run their marketplaces, the uninsured rate fell 5.3 percentage points. Through the first half of 2015, there are now seven states with uninsured rates that are at or below 5 percent: Rhode Island, Massachusetts, Vermont, Minnesota, Iowa, Connecticut and Hawaii. Previously, Massachusetts had been the only state to be at or below this rate. This data, collected as part of the Gallup-Healthways Well-Being Index, is based on Americans' answers to the question, "Do you have health insurance coverage?" The state-level data is based on daily surveys conducted from January through June 2015 and includes sample sizes that range from 232 randomly selected adult residents in Hawaii to more than 8,600 in California. Click here to read the report. August 17, 2015 Managed Care, Medi-Cal, Medicare Affordable Care Act, Health Insurance Exchange, Uninsured, ACA, Insurance 0 0 Comment Read More »
Changes to Anthem Blue Cross reimbursement policies and claims software Anthem Blue Cross recently notified physicians of upcoming changes to the insurer’s reimbursement policies and claims editing software, called ClaimsXten. The changes will go into effect on July 1, 2015. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated. Along with the notice, Anthem provided a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies. The changes include additions to the types of service Anthem will consider bundled with another procedure and thus will be ineligible for separate reimbursement (Policy CA – 0008). Anthem has also added to the list of CPT codes that will have a frequency edit (Policy CA – 0016), thus setting a limit on the number of units or number of times a code is eligible for reimbursement on a single date of service. A new frequency edit of note is a limit on the preparation of allergen immunotherapy of 120 doses per 365 days. Anthem has clarified to the California Medical Association (CMA) that it will consider payment for more than 120 doses per 365 days if there is a medical reason, and if the additional doses are actually received by the patient and not discarded as pharmaceutical waste. There are also new policies on cancer treatment planning (Policy CA – 0043) and documentation guidelines on psychotherapy services (Policy CA – 0047). While Anthem’s grid outlining policy changes indicates that the Multiple and Bilateral Surgery Processing policy (Policy CA – 0010) is existing, inferring there are no changes, CMA has identified that while the policy is not new, three new CPT codes (43233, 43266 and 43270) were added to the list of affected codes. These codes were newly added to the CPT manual in 2014. The policy states that when billing multiple esophagogastroduodenoscopy codes, practices will be paid 100 percent of the fee schedule for the primary procedure and 25 percent for subsequent procedures. At CMA’s suggestion, Anthem will update the policy grid to indicate this policy is “revised.” The most significant change, however, is a modification to Anthem’s policy on evaluation and management (E/M) services billed on the same day as a preventive exam (Policy CA – 0026). Effective July 1, 2015, when physicians bill a preventive visit on the same day as a problem-oriented E/M visit, Anthem will only reimburse the problem-oriented E/M visit at 50 percent of the physician’s contracted rate. While some other payors have similar policies, this will reflect a change in reimbursement for affected Anthem claims. To address this change, practices have the option of advising patients that a separate appointment is required to address the problem-focused issue. However, it will be important for practices to manage patient expectations. When the preventive services appointments are scheduled, staff should inquire with patients about whether they wish to discuss any other health issues with the physician and, if so, advise that a separate appointment will be required due to the plan/insurer’s policy. The practice can then schedule the problem-oriented visit first and schedule the preventive service for a later date. Even if the patient indicates he/she has no other health issues to discuss with the physician, the scheduler should advise the patient that if other health issues arise, another visit may be required. Physicians are encouraged to review all of the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices. Physicians can also access this information via the Blue Cross ProviderAccess website (log in, then select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section). Questions about any of the claims editing rules or payment policies can be directed to the Blue Cross Provider Care Department at (800) 677-6669. Contact: CMA reimbursement helpline, (888) 401-5911 or economicservices@cmanet.org. May 15, 2015 Managed Care Billing/Coding, Insurance, Managed Care, Anthem Blue Cross 0 0 Comment Read More »
Gallup poll finds U.S. uninsured rate at lowest level in seven years. According to a nationwide Gallup Poll, the Affordable Care Act (ACA) has steadily reduced the number of people without insurance across the United States. The group conducted phone interviews (landline and cell) in 2013 and 2014, as part of the Gallup-Healthways Well-Being Index, with a random sample of 178,072 adults in 2013 and 176,702 adults in 2014. The survey found that the nationwide rate of uninsured adults declined from 17.3 percent in 2013 to 13.8 percent in 2014. The lowest uninsured rates continue to be primarily in the Northeast and upper Midwest. Massachusetts, whose 2006 health care coverage expansion became the model for the national law, had the lowest rate at 4.6 percent. The highest uninsured rates are in the South and West. For the seventh consecutive year, Texas has the worst rate in the country, with nearly a quarter of its adults uninsured. California, historically the state with the highest uninsured rate, recorded one of the fastest declines. The share of adults without coverage in the state fell from 21.6 to 15.3 percent. States that have implemented a Medicaid expansion and state health exchanges are seeing a substantially larger drop in the uninsured rate than states that did not take both of these actions. The survey results came just a week before the U.S. Supreme Court hears oral arguments in a lawsuit challenging ACA’s core structure. On March 4, the court will hear King v. Burwell, a case that questions whether premium subsidies can be provided under the law to individuals purchasing health insurance coverage on exchanges run by the federal government. The lawsuit has the potential to affect 36 states that use the federal health care exchange, but would not change the subsidies in states like California that run their own exchanges. March 9, 2015 Managed Care Insurance, Uninsured, Affordable Care Act 0 0 Comment Read More »
Online tool that gives consumers average costs for over 70 medical procedures now live A new online tool that gives consumers an idea of the cost for several health care procedures went live last week. Launched by the Health Care Cost Institute (HCCI), an independent, non-partisan, non-profit organization, Guroo.com shows average amounts paid for over 70 common care episodes in most states, including much of California. Using data supplied by Aetna, Assurant Health, Humana and UnitedHealthcare, the website pulls cost information from the medical claims of more than 40 million U.S. residents. According to HCCI, the prices are averages of the total payments to providers (i.e., what the patients pays plus what the health plan pays) on adjudicated claims by geographic area. The information is put in consumer-friendly terms, with all the cost ranges provided for medical care that is “shoppable” – generally meaning it is elective and can be scheduled in advance. The new website is free and accessible to consumers, regardless of their insurance status or insurance company. The information is presented using care bundles (e.g., knee replacement, hip replacement) and summarizes the steps of care (when appropriate), showing the cost of each step. The tool also provides consumers with questions they can use when talking with their health care providers to better understand their choices and help achieve a quality health outcome. Although Guroo.com was designed specifically for consumers, HCCI hopes that this website will also be valuable to employers, policymakers and regulators who can now assess prices and compare costs nationally and locally. HCCI said it also aims to help consumers learn more about their health care conditions, including the common progression or likely steps of care, what to expect and how to prepare for their doctor visit. While the tool does not yet give provider-specific prices, within a year HCCI expects to let members of UnitedHealthcare, Aetna, Assurant and Humana track spending on a companion site and check how switching caregivers could lower their out-of-pocket costs. Currently, the database populating the website contains approximately 3 billion claim lines and will be adding 214 care bundles in June. HCCI says that before the end of 2015, it hopes to grow the database to contain claims data from over 100 million Americans, with the addition of Medicare claims data, making it the largest public database of its kind. The website will also add a quality of care feature in the future, though HCCI is still in the early stages of planning the quality component. Under a federal grant, the California Department of Insurance is continuing to pursue the development of a similar database, though on a much smaller scale, called the California Online Medical Price and Quality Transparency (COMPAQT) initiative. The COMPAQT website currently is scheduled to go online this year, providing cost and quality ratings around five health conditions. Considering the potential for databases such as these to be used by more patients over the next year, physician practices may want to familiarize themselves with the information being provided on websites such as Guroo.com. Because the cost information provided on Guroo.com depends largely on the allowable amounts paid by the aforementioned insurers, it may differ significantly with the billed charges quoted to any particular patient and lead to a desire for more information from the patient on the cost of a service, particularly for those patients who may still be under their deductible. Contact: Brett Johnson, (800) 786-4262 or bjohnson@cmanet.org. March 2, 2015 General Insurance, United Healthcare, Aetna 0 0 Comment Read More »
State issues report cards for HMOs, PPOs and large medical groups The California Office of the Patient Advocate yesterday released its 14th annual “California Health Care Quality Report Cards” that rate the state's health plans and medical groups on a four-star scale. Available in English, Spanish and Chinese, the report cards allow consumers to compare the quality of care that more than 16 million commercially insured consumers receive from the state’s 10 largest HMOs, six largest PPOs and more than 200 medical groups. The data for the report cards is drawn from claims data and patient surveys for 2013. Users can drill-down online to see specific plan performance on topics of greatest interest to them, such as chronic disease management, pediatric care and mental health care. Although the report cards are usually published annually in January, officials have changed the release date so it would coincide with the fall open enrollment period for many Californians and their families, including those purchasing coverage through Covered California, the state's health benefit exchange. Covered California's next open enrollment period runs from November 15 to February 15.The report cards are part of a larger national push to bring greater transparency to the health care industry and help consumers choose services that best fit their needs. The report cards are available at the Office of the Patient Advocate's website. October 17, 2014 General Insurance/Reimbursement, Insurance 0 0 Comment Read More »
