The California Department of Health Care Services (DHCS) recently announced new continuity of care rules for the Cal MediConnect duals demonstration project. The project – an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities – transitions a large portion of the state's dual eligible beneficiaries to managed care plans.
Although the program already had continuity of care provisions, the new rules make it easier for a patient to continue receiving needed care from out-of-network physicians without interruption.
The new continuity of care rules allow beneficiaries who meet certain criteria to keep their current providers for up to six months for Medicare services and up to 12 months for Medi-Cal services. Patients must demonstrate they’ve seen the out-of-network physician at least once in the previous 12 months for primary care and twice in the previous 12 months for specialists.
Providers can request continuity of care
The new rules will now allow providers to request continuity of care for their patients under the duals demonstration project. Previously, only the patient could initiate such a request. This new rule will help beneficiaries who have difficulty navigating the health care system so they can maintain their provider for up to 12 months.
Continuity of care can be requested via telephone
Under the new rules, continuity of care requests can be made via telephone and plans will be prohibited from requiring beneficiaries to submit a request through a paper form.
Plans must process request within 3 days
Under the new rules continuity of care requests must be processed within three days if there is a risk of harm to the beneficiary. Urgent requests will be processed within 15 days and all other requests are to be processed within 30 days.
Retroactive continuity of care
Under these new rules, providers or the beneficiary can now request continuity of care after delivering the service – ensuring payment for treatment. To qualify, the request must be received within 20 business days of the first service following the beneficiaries’ enrollment in Cal MediConnect. Once a beneficiary is approved for continuity of care, providers must work with the health plans to ensure compliance with the plan’s utilization and management policies.
These changes in continuity of care do not apply to providers of DME, transportation or ancillary services.
DHCS is expected to release a Dual Plan Letter within the next few weeks with direction on the new continuity of care rules for the Cal MediConnect population with an effective date.
CMA is pleased with the efforts DHCS has made to strengthen the physician-patient relationship and will continue to work with the department in ensuring adequate access to care.
The California Medical Association (CMA) sent a letter to the Centers for Medicare & Medicaid Services (CMS) commenting on the proposed rules that would impact many aspects of physician payment and federal regulatory programs for 2015.
The 39-page letter strongly opposes the agency's plan to accelerate the implementation of the value-based modifier (VBM) payment methodology. CMS has said it will expand the VBM to all physicians in 2017 and increase the potential penalty from 2 percent to 4 percent.
CMA also argued that because the agency is ignoring the law that requires CMS to adjust the payment rates for the socioeconomic characteristics of the patients the VBM could discourage physicians from accepting the sickest and poorest patients. The value modifier was enacted by Congress as part of the Affordable Care Act (ACA). A CMA amendment to the law required CMS to risk-adjust the rates, adjust for California’s higher geographic practice costs and certain socioeconomic factors. The VBM is supposed to pay physicians more if they spend less than the national average per patient and successfully report on quality measures. It pays physicians less if they spend more than the national average and do not report on quality.
CMA also urged the agency to make revisions to the practice expense relative value units and improvements to the valuation and coding of the global service package. The letter also calls upon CMS to allow physicians to opt-out of Medicare indefinitely rather than every two years, to take CME reporting out of the Physician Payment Sunshine Act, and to scale back the Physician Compare Website until the accuracy of the information can be verified.
CMS has also proposed increasing from 3 to 9 the number of quality measures that physicians must report in order to avoid a 2 percent payment penalty under the Physician Quality Reporting System). CMA and AMA oppose the quality measure increase and have asked CMS to stabilize the quality measures so they are not changed on a yearly basis.
CMA applauded the expansion of payment for telemedicine services and payment for non-face-to-face visits for managing the care of the chronically ill.
More than 2,000 comments were received on the 600-plus-page proposed rule. A final version is expected to be released by Nov. 1.
Contact: Elizabeth McNeil, (800) 786-4262 or firstname.lastname@example.org.
After advocacy from the California Medical Association (CMA) in conjunction with patient advocacy groups, the California Department of Health Care Services (DHCS) has revised its “Choice Forms” that allow dual eligibles to opt-out of the Cal MediConnect duals demonstration project and remain in traditional Medicare fee for service.
The project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that transitions a large portion of the state's dual eligible beneficiaries transition to managed care plans. The project will impact approximately 450,000 duals in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara.
The previous Choice Forms did not make it clear how a patient could opt-in or out of the program and DHCS was criticized for its lack of transparency in the documents. CMA was very vocal in requesting DHCS change the forms to clearly state the patient’s options. The state hopes the new forms provide clarity and make it easier for patients to make the choice between opting into the Cal MediConnect program or opting out of it. The Spanish language forms were also revised.
The updated forms are found here and should be included in new Plan Choice books for newly enrolled members. The plan Choice Form is located in the middle of the Plan Choice Book.
DHCS will also soon be finalizing a physician toolkit to help physicians and their patients understand the project. The toolkit has been developed in conjunction with Harbage Consulting and various stakeholder groups. The various pieces of the toolkit will be released individually as they are finalized. Watch DHCS’s weekly Coordinated Care Initiative updates for more information.
Last fall, the Centers for Medicare and Medicaid Services experienced some editing issues with new patient evaluation and management (E&M) codes that resulted in incorrect claim denials. These issues began in October 2013, and were thought to have been corrected in late January 2014. The California Medical Association recently learned, however, that some claims continued to be denied incorrectly through July 15, 2014.
In January, Noridian, California's Medicare contractor, began reprocessing claims that had been denied in error and correcting those subjected to overpayment recovery. Unfortunately, while implementing the corrections, Noridian inadvertently applied the edit to established patient E&M codes 99211-99215, again resulting in incorrect denials
Noridian has corrected the editing for both the new patient codes and the established patient codes, and claims received by Noridian on and after July 16, 2014, should be processed correctly.
Noridian estimates that about 300,000 claims were denied in error, dating back to October 2013, and is now working on reprocessing all affected claims. It expects to complete the reprocessing project around the end of September.
Physicians do not need to resubmit the claims to Noridian. The claims will be automatically adjusted.
For more information, see Noridian's July 22 notice on this issue.
A newly released study by the federal General Accounting Office (GAO) found that the Centers for Medicare and Medicaid Services (CMS) needs to provide better oversight and guidance for provider payment auditors to prevent duplicative post-payment claims review audits.
Several types of Medicare contractors conduct postpayment claims reviews to help reduce improper payments: Medicare Administrative Contractors, which process and pay claims; Zone Program Integrity Contractors, which investigate potential fraud; Recovery Auditor Contractors, tasked with identifying on a postpayment basis improper payments not previously reviewed by other contractors; and the Comprehensive Error Rate Testing contractor, which reviews claims used to annually estimate Medicare's improper payment rate.
The report notes that although CMS implemented a database to track audit activities, designed in part to prevent duplicative audits by multiple contractors, it must do more to ensure that auditors are not completing duplicative reviews. The report notes that the database was not designed to provide information on all possible duplication, and found that it's data is not reliable because other postpayment contractors do not consistently enter information about their reviews.
The report concludes that CMS has not provided sufficient oversight of this data or issued complete guidance to contractors on avoiding duplicative claims reviews.
GAO recommends that CMS take actions to improve the efficiency and effectiveness of contractors' post-payment review efforts, which include providing additional oversight and guidance regarding data, duplicative reviews and contractor correspondence. In its comments, the U.S. Department of Health and Human Services concurred with the recommendations and noted plans to improve CMS oversight and guidance.
Click here to read the full report.
Last week, the Sacramento Superior Court denied a request to delay implementation of the Cal MediConnect project. In a last minute challenge to the program, the Los Angeles County Medical Association (LACMA) joined a coalition of plaintiffs, including three Los Angeles independent living centers, to file a lawsuit in Sacramento Superior Court to stop the implementation of the project.
The Cal MediConnect project was authorized by the state in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that will see a large portion of the state's Medicare/Medi-Cal dual eligible beneficiaries transition to managed care plans. The project will impact approximately 456,000 dual eligible beneficiaries in eight counties – Alameda, Los Angeles, Orange, Riverside, San Diego, San Mateo, San Bernardino, and Santa Clara.
The lawsuit alleged that Cal MediConnect is not legally authorized because DHCS failed to obtain timely federal approval of the demonstration project as required under the state law establishing the project. Second, the lawsuit alleged that there are deep flaws with the implementation of the project thus far, including problems with the notices to beneficiaries and the enrollment form. Specifically, the lawsuit alleged the notices were not written at a 6th grade reading level as required by law and in addition, the enrollment form is too confusing to meaningfully provide an opt out choice for beneficiaries.
The California Medical Association (CMA) was not a named party in the lawsuit. However, CMA believes the lawsuit raises legitimate issues about the rollout and implementation of Cal MediConnect, specifically concerning adequate notice and information to affected beneficiaries and providers.
In an unrelated move, the Department of Health Care Services (DHCS) has delayed the implementation of the Cal MediConnect project for Alameda and Orange counties until July 2015.
CMA will continue to work with DHCS and other stakeholder groups to identify suggestions for improvement in the Cal MediConnect implementation and rollout.
To see the current timeline for implementation of Cal MediConnect program, click here.
Noridian, the Medicare Administrative Contractor for California, has scheduled a series of one-hour webinars during the month of August. Topics include common errors, global surgery and a series of three webinars titled “Climbing The Ladder To Success.” (For details on each workshop, click on the title.) Continuing education units are offered for most workshops.
The Centers for Medicare and Medicaid Services (CMS) recently published the 2015 proposed Medicare physician payment rule in the Federal Register. The proposal contains several notable changes. The rule expands the services eligible for telemedicine reimbursement (psychotherapy services and the annual wellness visit). It also extends the new payment policies for non-face-to-face care coordination. It allows primary care physicians to be paid for care management of Medicare beneficiaries with two or more chronic conditions. These are tasks (including managing lab and imaging reports, medications and care plans in addition to talking with patients and families on the phone) physicians commonly provide, but have not been paid for in the past.
In a radical move, the rule proposed the elimination of all 10- and 90-day global surgical packages by 2018 because CMS says it lacks the ability to verify the number, type and relative costs of postoperative visits. Packages would only include preoperative services and care given the day of surgery. The American Medical Association (AMA) and the California Medical Association (CMA) are protesting this proposal.
CMS also continues to move up the implementation timeline for the Value-Based Payment Modifier. Physician groups of 100 or more will be eligible for the Value-Based Payment Modifier (VBM) penalties or bonuses in 2015 based on 2013 cost and quality performance. Groups of 25 to 100 physicians will be eligible in 2016 based on 2014 performance. The program will be expanded to all physicians in 2017 based on performance in 2015 and penalties will be doubled to 4 percent.
To get an idea of how they are likely to score in the VBM, physicians should review the confidential feedback reports that were also required by law and are known as Quality and Resource Use Reports (QRURs). Reports based on 2012 data became available to groups of 25 or more last fall and are still open for review. Starting in the fall of 2014, reports based on the prior year’s data will be made available for all physician groups as well as solo physicians.
AMA and CMA have called for a slower phase-in of the VBM. CMA is supporting the VBM program reforms in the Medicare sustainable growth rate (SGR) overhaul legislation (HR 1415/S 2000), which includes large bonus payments. There are also new requirements for the Physician Quality Reporting System (PQRS) and a continuation of the 2 percent penalty.
CMS reiterated its support for legislation to permanently repeal the Medicare SGR formula. Legislation passed earlier this year to prevent SGR physician pay cuts through March 2015. CMS projects that payments would be reduced by 20.9 percent when the patch expires on March 31, 2015.
Comments are due on Tuesday, September 2, with a final rule to be issued on or around November 1, for implementation on January 1, 2015. CMA and AMA will be submitting extensive comments.
To view the AMA summary of the whole 2015 Medicare physician fee schedule, click here.
Trustees overseeing Medicare’s Hospital Insurance Trust Fund, which finances about half the health program for seniors, said Monday in a report that the program won’t run out of money until 2030 – that’s four years later than projected last year and 13 years later than projected at the passage of the Affordable Care Act (ACA).
The outlook for Medicare improved largely because of lower-than-expected hospital spending and savings resulting from the ACA. The effect of the new law encouraged providers and Medicare Advantage insurers to deliver care more cost-effectively and also reduced payments to hospitals and providers. Some of the cost savings may also be the result of a sluggish economy and continued high unemployment, the report said.
The report also predicts that the average spending per Medicare beneficiary will grow about 40 percent in the coming decade, to $17,360 in 2023, with outlays expected to rise much faster for prescription drugs and doctors’ services than for inpatient hospital care.
The trustees took out the sustainable growth rate (SGR) cut to physician reimbursement for the financial projections for this report. Leaving out the SGR cuts should make the cost projections more solid as they are based on realistic assumptions of a modest physician pay hike rather than an unrealistic pay cut that Congress has stepped in to stop for the past 11 years.
The report shows that the slowdown in Medicare spending growth has been dramatic. Medicare, which covered an estimated 52.3 million people in 2013, spent $582.9 billion last year, with per beneficiary spending essentially unchanged from the previous year. According to an analysis released by the Department of Health and Human Services (HHS) Monday, the annual per capita growth rate from 2000-2008 was 6.3 percent. That growth slowed to 2 percent from 2009 to 2012. In 2013, that rate fell to nearly zero, and, so far in fiscal year 2014, growth in per person Medicare spending is at or below zero.
To read the report, click here.