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Patient outcomes shortchanged by prior authorization

More than nine in 10 physicians (92 percent) say that prior authorizations programs have a negative impact on patient clinical outcomes, according to a new physician survey by the American Medical Association (AMA). The survey results further bolster a growing recognition across the entire health sector that prior authorization programs must be reformed.

According to the AMA survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64 percent) report waiting at least one business day for prior authorization decisions from insurers—and nearly a third (30 percent) said they wait three business days or longer.

 “Under prior authorization programs, health insurance companies make it harder to prescribe an increasing number of medications or medical services until the treating doctor has submitted documentation justifying the recommended treatment,” said AMA Chair-elect Jack Resneck Jr., M.D., a dermatologist and health policy expert from the San Francisco Bay Area. “In practice, insurers eventually authorize most requests, but the process can be a lengthy administrative nightmare of recurring paperwork, multiple phone calls and bureaucratic battles that can delay or disrupt a patient’s access to vital care. In my own practice, insurers are now requiring prior authorization even for generic medications, which has exponentially increased the daily paperwork burden.”

High wait times for preauthorized medical care have consequences for patients. More than nine in 10 physicians (92 percent) said that the prior authorization process delays patient access to necessary care; and nearly four in five physicians (78 percent) report that prior authorization can sometimes, often or always lead to patients abandoning a recommended course of treatment.

In addition, a significant majority of physicians (84 percent) said the burdens associated with prior authorization were high or extremely high, and a vast majority of physicians (86 percent) believe burdens associated with prior authorization have increased during the past five years.

The survey findings show that every week a medical practice completes an average of 29.1 prior authorization requirements per physician, which takes an average of 14.6 hours to process—the equivalent of nearly two business days. To keep up with the administrative burden, about a third of physicians (34 percent) rely on staff members who work exclusively on the data entry and other manual tasks associated with prior authorization.

“The AMA survey illustrates a critical need to help patients have access to safe, timely, and affordable care, while reducing administrative burdens that take resources away from patient care,” said Dr. Resneck. “In response, the AMA has taken a leading role in convening organizations representing, pharmacists, medical groups, hospitals, and health insurers to take positive collaborative steps aimed at improving prior authorization processes for patients’ medical treatments.”

In January 2017, the AMA with 16 other associations urged an industry-wide reassessment of prior authorization programs to align with a newly created set of 21 principles intended to ensure that patients receive timely and medically necessary care and medications and reduce the administrative burdens. More than 100 other health care organizations have supported those principles.

In January 2018, the AMA joined the American Hospital Association, America’s Health Insurance Plans, American Pharmacists Association, Blue Cross Blue Shield Association and Medical Group Management Association in a Consensus Statement outlining a shared commitment to industry-wide improvements to prior authorization processes and patient-centered care.

Please visit the AMA website to learn more about the organization’s ongoing efforts on prior authorization reform.
April 5, 2018 Managed Care American Medical Association, Managed Care 0 0 Comment Read More »

DMHC orders 600,000 patients transferred from troubled medical group

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. The health plans affected by this order must transfer all EHS patients to different health care providers by early February 2018. The plans were required to submit a transition plan to DMHC by January 3, 2018, with a “Final Proof of Compliance” confirming termination of the plans’ relationships with EHS due by February 5, 2018.

In the cease-and-desist order, DMHC describes how SynerMed secretly and systematically blocked patients and providers from accessing contracted specialists deemed too costly. As part of its administration of the EHS provider network, SynerMed provides an electronic online provider portal where contracted physicians can view the available EHS-contracted medical specialists in their region.

In June, SynerMed’s CEO issued a “Contracting Playbook” that listed five directives aimed at lowering specialist costs for EHS. In implementing this playbook, SynerMed staff were affirmatively directed to suppress “high cost” providers from the referral system, including cardiologists, diagnostic radiologists, dialysis providers, hematologists, oncologists, nephrologists, ophthalmologists and rheumatologists. According to DMHC, SynerMed actively and secretly restricted “high cost” specialists who maintained contracts with EHS from delivering care to EHS enrollees. Though these specialists continued to maintain contracts with EHS, enrollees as a practical matter had no access to these suppressed providers, which SynerMed unilaterally deemed to be too expensive.

Under California law, health plans must notify the state of any policies that deny patients access to contracted providers based on cost — a practice called "economic profiling." Plans must demonstrate that their economic profiling practices would be consistent with the requirement that medical decisions be rendered by qualified medical providers, unhindered by fiscal and administrative management.

While there is no indication that the health plans were privy to SynerMed’s effort to narrow EHS’s specialist network, DMHC has found the plans to be in violation of the state law because none of them filed the requisite economic profiling policy.

The health plans are working with DMHC to minimize disruption of care, but it is unknown at this time where affected patients will be transferred. It is also unclear how claims processing functions, including preauthorizations, will be handled during the transition. The California Medical Association is working to obtain additional information and will publish an update as soon as we have more details. 
January 30, 2018 General, Managed Care, Medi-Cal Department of Managed Health Care, Managed Care, Medi-Cal 0 0 Comment Read More »

CHPI publishes physicians' quality ratings for cycle 2

On March 22, 2017, the California Healthcare Performance Initiative System (CHPI) released its second cycle of physician quality ratings to the public. The ratings can be accessed at CHPI’s newly launched website, CAqualityratings.org, which allows consumers to search ratings on approximately 10,000 California physicians. 

As previously reported in September 2016, approximately 13,000 physicians in California received their individual quality measurement scores for the second cycle of the CHPI quality rating program. The program rates physicians using claims data from Medicare fee-for-service, Anthem Blue Cross, Blue Shield of California and UnitedHealthcare. 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.

For more information on the CHPI Cycle 2 rating methodology, visit the CHPI website at www.chpis.org. CHPI has also published an FAQ on its rating program. If you have questions or concerns about the CHPI rating results, email chpicorrections@pbgh.org and expect a response within 48 hours.

April 19, 2017 Managed Care, Medicare Managed Care, Medicare, CHPI, Quality of Care 0 0 Comment Read More »

Health Net Federal Services begins TRICARE contracting initiative

As previously reported, the Department of Defense awarded the $17.7 billion TRICARE West Region contract to Health Net Federal Services (HNFS). As the recipient of the contract, HNFS will provide managed care services to 2.9 million TRICARE beneficiaries in 19 western states, including California, beginning October 1, 2017.

In preparation for the transition, Health Net has sent recruitment notices to physicians soliciting interest in participation in the new Health Net Federal Services (HNFS) West Region network.

Included in the recruitment packet is a “Join our Network” form. Physicians interested in joining the HNFS network should return the completed form to HNFS via email, fax or mail. According to Health Net, submission of the “Join our Network” form is only an expression of interest and does not obligate the physician to participate. HNFS will then mail the physician a contract offer approximately 72 hours after receipt of the completed form. Physicians will have the opportunity to review the contract terms before making a final decision.

Physicians should be aware that terms of the HNFS contract may vary from the prior United Healthcare Military and Veterans (UMVS) TRICARE contract. Providers are encouraged to closely review the proposed contract terms.

The California Medical Association (CMA) is in the process of reviewing the HNFS contract and will publish an update as soon as more information is available.

During the 2013 transition of TRICARE managed care services from TriWest to UMVS, a CMA survey found widespread reports of problems, including contracting issues and significant delays in processing of authorizations and referral requests, which delayed timely access to medical care. CMA has shared feedback with HNFS on the flawed transition to UMVS. HNFS advised that it has been a continuous TRICARE administrative contractor for 28 years, has an existing medical management system in place in the North Region that it will be utilizing and that it, along with the Department of Defense, is taking proactive steps to ensure the transition goes smoothly. CMA will work closely with HNFS on the transition and will be publishing a TRICARE transition guide to provide assistance to physician practices.

Physicians with questions regarding the TRICARE amendment may contact HNFS at HNFSProvRel@healthnet.com.

April 18, 2017 Managed Care Health Net Federal Services, HNFS, Managed Care, TRICARE 0 0 Comment Read More »

Know Your Rights: Managed care contractual protections

CMA’s “Know Your Rights” series summarizes vital protections under state and federal law that physicians should be aware of in their dealings with payors.

Thanks to legislation sponsored by the California Medical Association (CMA), all health plan contracts with physicians are required to be fair, reasonable and consistent with California law and regulations. Contractual clauses that are specifically prohibited cover the following:

Physicians who believe their contracts violate any of these laws are urged to contact CMA's Center for Economic Services (CES) at (888) 501-4911 or economicservices@cmanet.org.

CMA managed care contracting resources
Payor contract negotiations can be difficult. The California Medical Association (CMA) offers a number of free resources and services to help members and their staff simplify the contract review, negotiation and renegotiation process.

Contracting education and coaching:

CES provides one-on-one education and coaching on confusing or problematic managed care contracting issues. Contact CMA's reimbursement help line at (888) 401-5911 or economicservices@cmanet.org.

  • "Taking Charge: A step by step guide to evaluate and prepare for negotiations with managed care payors": This toolkit provides physicians and their office staff with practical tips and tools to assist with the negotiation, implementation and ongoing management of complex managed care contracts. The toolkit includes sample forms and letters that may be customized for each medical practice.
  • "Contract Renegotiations: Making Your Business Case": When submitting a request to open up a contract renegotiation discussion, best practice is to present a “business case” as to why the payor wants to keep your practice in the network. This resource will help physicians present a thoughtful renegotiation request meant to avoid the quick “auto-reply” from the payor indicating that they are not in a position to renegotiate at this time.
  • Health plan contract analyses: CMA provides objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification.
  • "Contract Amendments: An Action Guide for Physicians": This guide is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy or procedure.
  • Financial Impact Worksheet: It is important that physicians understand how a fee schedule can affect their practice's bottom line so they can make informed decisions about health plan participation before contracts are signed. CMA has developed a simple worksheet to help physicians analyze proposed fee schedules and assess the impact fee schedule changes may have on their practices based on commonly billed CPT codes.
  • Payor profiles: CMA's payor profiles include information for each of the major payors in California, including important contact numbers, addresses, and links for quick reference for payor interactions.
  • "Best Practices: A guide for improving the efficiency and quality of your practice": This toolkit offers a series of proven steps that solo and small group practices can take to improve many facets of their practice. Chapter IX, "Surviving Out of Network: One Physician's Experience," offers practical advice, including tips on developing an out-of-network strategic plan.
CMA On-Call

CMA's health law library, CMA On-Call, includes several documents that address managed care contracting, including but not limited to:

Contract analysis service

CMA-contracted attorneys provide written reviews of physician contracts for physician members. Contracts are reviewed for compliance with California and federal law and to determine whether, from a business and practical perspective, the provisions of the contract are beneficial for the physician or group. CMA members receive a 20 percent discount on the attorney fees when using one of CMA's contracted attorneys. For more information on CMA's contract analysis service, see On-Call document #7076, "CMA Contract Analysis Service."

Tip: Physicians do not have to accept substandard health plan contracts. You can and should negotiate your contracts.

October 13, 2016 Managed Care Know Your Rights, Managed Care, Payor Contracting 0 0 Comment Read More »

California lawmakers unveil bill to tax MCOs and plug $1.1 billion hole in budget

California lawmakers on Monday unveiled two identical bills to replace the soon-to-expire tax on managed care organizations (MCO). The bills, ABx2 20 (Bonta) and SBx2 15 (Hernandez), are the product of 14 months of negations with MCOs. These bills are supported by the California Association of Health Plans, with most member plans either supportive or neutral.

The current MCO tax will expire this summer if legislators cannot agree on a replacement. Since 2005, the state has taxed MCOs and used the money to cover the costs of the Medi-Cal program. However, federal officials in 2014 informed California that its MCO tax structure was not compliant with federal requirements. Since then, the California Department of Health Care Services and other administration officials have been negotiating with the health plans to construct a tax scheme that meets federal standards. The loss of the MCO tax and the federal matching funds would mean a devastating loss of over $2 billion for the Medi-Cal program.

These bills create a new MCO tax scheme by establishing various taxing tiers and per-enrollee amounts in order to account for the various health plan sizes licensed under the Department of Managed Health Care. They would exempt health plan income from the state’s gross premiums tax in an effort to offset the impact this tax will have on the non-Medi-Cal, commercial lives. The legislation would impose a new MCO tax until June 30, 2020, at which point the tax would sunset.

Bipartisan support in the Assembly and Senate is needed to get the required supermajority to pass a tax increase.

Gov. Jerry Brown called a special session of the state legislature in fall 2015 to deal with health care financing, but lawmakers failed to find a solution for the budget hole. His administration has worked for months to broker a compromise with insurance plans.

The bill could begin moving through legislative committees as soon as this week.

Contact: Eduardo Martinez, (800) 786-4262 or emartinez@cmanet.org.

February 16, 2016 Managed Care, Medi-Cal Medi-Cal, State Legislation, Managed Care, Managed Care Organization (MCO) 0 0 Comment Read More »

California Medical Association responds to unveiling of Governor Brown's proposed 2016-17 state budget

Sacramento – Steve Larson, M.D., president of the California Medical Association (CMA), representing over 41,000 physicians statewide, issued the following statement in response to the unveiling of Governor Brown’s proposed 2016-17 state budget released this morning:

“We are pleased to see the Governor is committed to working with the legislature and health plans to find a solution to the MCO tax. Without that, a gaping hole would exist in the state’s Medicaid (Medi-Cal) fund that would have devastating impacts on patients across the state.

“Ensuring that Medi-Cal is better funded is a priority of CMA, and as sponsors of the California Healthcare, Research and Prevention Tobacco Tax Act of 2016, we will be focused on passing the ballot measure both to help save lives and fund health care programs in California.

“With over one third of the state’s population relying on Medi-Cal for health care coverage, it’s essential that access to care is a reality for those patients and not just an empty promise with an insurance card.” 
January 15, 2016 General, Managed Care, Medi-Cal Managed Care, Medi-Cal, Save Lives California, Tobacco Tax, California State Budget 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 »

Anthem system error results in missing remittances

In early February, the California Medical Association (CMA) began receiving reports from practices of missing Anthem Blue Cross remittances. CMA escalated the issue to the payor and has since learned that a system issue is to blame for the missing electronic remittance advices (ERA).

Anthem reports that the problem began in mid-December and affected ERAs for exchange/mirror and Federal Employee Program (FEP) claims. Somehow, the ERA function was turned off in the Anthem system for these product types. So, while practices received the money for the affected claims through electronic funds transfer (EFT), they have not yet received the detailed claims information in order to post to individual accounts.

A system fix was put into place on February 16 to fix the issue going forward. Practices can obtain missing ERAs through the ProviderAccess portal on the Anthem website or can contact Anthem customer service:

  • For missing FEP remittances: (800) 322-7319
  • For missing Covered California remittances: (855) 854-1438
CMA had also received some reports of missing CalPERS ERAs; however, Anthem reports the CalPERS issue was unrelated to the issue affecting exchange/mirror and FEP ERAs. Rather, it was due to a recent change in CalPERS claims processing that resulted in a several week delay in processing of ERAs. Physicians who are still missing CalPERS remittances can call (800) 677-6699 to request them.

March 17, 2015 Managed Care Anthem Blue Cross, Insurance/Reimbursement, Managed Care 0 0 Comment Read More »

United Healthcare to host webinars about its Premium Designation Program for contracted physicians

At the request of the California Medical Association, United Healthcare (UHC) is inviting physicians and practice administrators to attend a special webinar presentation about its Premium Designation program in California. The webinars will be offered in mid-November and will provide an overview on the background and methodologies of the Premium Designation program and allow physicians an opportunity to ask specific questions they may have.

The webinars will take place on the following dates and times. Participants will need to register with UHC prior to attending. Click the registration links below for more information.

November 10, 2014 Managed Care Insurance/Reimbursement, Managed Care, Webinars, United Healthcare 0 0 Comment Read More »