What you need to know about Blue Shield of California's Care1st integration On January 1, 2019, Blue Shield of California will complete the integration of Care1st Health Plan into its operations, and Care1st’s name will change to Blue Shield of California Promise Health Plan. The newly renamed health plan will remain a separate company and a wholly owned subsidiary of Blue Shield of California. Care1st physicians serving Medicare Advantage HMO, Medi-Cal or Cal MediConnect members will not need to contract with Blue Shield of California to continue providing services, and participating physicians will receive a mailed contract amendment later this year that reflects the name change. The contract amendment only refers to the name change and will not impact reimbursement rates or other material changes. In addition, the migration of member and provider data to improve information-technology infrastructure will result in several changes requiring some action on the part of current Care1st network providers, including new provider ID numbers, member ID numbers and member ID cards, as well as changes to submission processes for encounter data. Greg Buchert, M.D., MPH, president and CEO of Care1st, and a California Medical Association (CMA) member for 27 years, has provided a Q&A for CMA members to learn more about the transition – learn more by downloading here. October 16, 2018 General, Managed Care Commercial Payors, Payor Contracting, Payor Issues and Reimbursement 0 0 Comment Read More »
Health Net Federal Services continues to address TRICARE transition issues As previously reported, Health Net Federal Services (HNFS) has experienced implementation issues since taking over as the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region on January 1. In recent discussions with the California Medical Association (CMA), HNFS said it continues to address the breakdowns in process and resulting consequences that have impacted TRICARE providers in the areas of provider contracting and credentialing, beneficiary reassignment and provider directory inaccuracies. Updates are as follows: Contracting and Credentialing Because of staffing and operational issues, physicians may have experienced problems during the contracting and credentialing process including the following: Completed provider contracts not entered into the HNFS system HNFS unable to locate countersigned provider contracts Cases where the contracting or credentialing processes were never completed HNFS shared with CMA that it has identified the providers impacted by the breakdowns and is nearing completion of the credentialing and contracting cleanup for these impacted providers. Additionally, HNFS will begin scaling back efforts to contract with former United Military and Veteran Services (UMVS) providers except to address network adequacy requirements. Physicians with questions about their contracting and/or credentialing status with HNFS can check the HNFS credentialing status tool at www.tricare-west.com. Physicians experiencing challenges with the credentialing or contracting process should contact Megan Herrera, Director of HNFS Provider Network Management, at (619) 285-3607 or megan.herrera@hnfs.com. Beneficiary Reassignment to New PCMs During the TRICARE transition, DHA allowed TRICARE Prime beneficiaries to receive care from primary care managers (PCMs) previously in the UMVS network who were not yet in the HNFS network, without incurring out-of-network fees through June 30. The purpose was to allow HNFS additional time to contract with providers, develop its provider network and address operational challenges within the contracting/credentialing process. When the transition ended, approximately 44,000 California enrollees, assigned to 3,800 out-of-network PCMs, were reassigned to HNFS network PCMs. This large number was due in part to the contracting/credentialing problems described above. HNFS reports that to date, 15,000 of those members have been reassigned to their original PCMs with approximately 23,500 members still assigned to new PCMs. Physicians with concerns or who have been affected by the reassignment of their patients to a HNFS network PCM, should visit the HNFS Tricare West website for more information. Provider Directory Inaccuracies HNFS continues efforts to correct the significant number of provider directory inaccuracies through its third party vendor, LexisNexis. While improved accuracy of its provider directory is expected over the next 30-120 days, HNFS reports that the error rate of several directory samplings remains high. Practices are encouraged to check the HNFS online provider directory to confirm participation status and demographic information. If demographic updates are needed, physicians can submit updates via HNFS’ online tool with routine changes to be completed within 14 calendar days and urgent or high priority updates processed within 24 hours. CMA is working with HNFS to ensure these issues are resolved quickly and adequately. HNFS has advised that updated transition information is available via the HNFS TRICARE Transition FAQ on the HNFS west website. Physicians with questions or concerns can contact Megan Herrera, Director of Provider Network Management at (619) 285-3607 or megan.herrera@hnfs.com. September 12, 2018 Managed Care Commercial Payors, Payor Contracting, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
New Medi-Cal provider enrollment system to go live Sept. 4 The California Department of Health Care Services (DHCS) is releasing an update to its Medi-Cal provider enrollment system—called the Provider Application and Validation for Enrollment (PAVE)—on Tuesday, September 4, 2018. The current iteration (2.0) of the PAVE system, launched on November 18, 2016, transformed DHCS’ provider enrollment from a manual paper-based process to a web-based portal that providers could use to complete and submit their applications, verifications and to report changes. Version 2.0 included most physicians and allied provider types. The new 3.0 update will include even more eligible provider types, including physician-owned ambulatory surgical clinics. PAVE will eventually replace the paper application process, although the paper option will still be available to those providers who specifically request it from DHCS’s Provider Enrollment Division. Key features of PAVE 3.0 include auto population of data, secured inter-practice communication, screening tools to avoid submission of the incorrect form, real-time status tracking and multiple “help” functions. According to DHCS, the process for completing an application through the new system is dramatically streamlined, dropping the average to complete an application from 1.75 hours to 0.7 hours. DHCS also reports its average provider application processing time has been cut in half, and it expects that time to drop even lower after 3.0’s launch. PAVE Provider Trainings DHCS will be offering three webinars to go over the PAVE basics that apply to all providers, as well as key features of the new 3.0 release. Each session covers the same content. Webinars will be offered on September 4, 11 and 12. To register, visit the DHCS PAVE webpage. For more information about PAVE, see the DHCS PAVE FAQ. August 29, 2018 Medi-Cal Payor Contracting, Public Payors 0 0 Comment Read More »
UnitedHealthcare Community Plan preps for entry into additional Medi-Cal and Medicare Advantage markets Looking to potentially enhance its footprint in the Medi-Cal and Medicare Advantage marketplace by 2021, UnitedHealthcare (UHC) Community Plan of California has issued unilateral contract amendments to contracted physicians in seven California counties. Additionally, UHC providers in the seven counties who are not currently contracted for the Medicare Advantage product will receive a combined contract amendment for participation in both UHC Community Plan of California (Medi-Cal) and UHC Medicare Advantage products. As a condition of participation in the Medi-Cal Managed Care request for proposal process in late 2019 or early 2020, UHC must demonstrate an adequate network of participating providers as part of its bid to the Department of Health Care Services (DHCS). Under the terms of the amendment, physicians will automatically be opted into the Medicare Advantage network and/or Community Plan network unless a written request to opt out has been submitted to UHC Community Plan within 45 days of receipt of the amendment. Physicians may opt out of the amendment without affecting their underlying UHC commercial contracts by issuing a letter to: UnitedHealthcare Physician Contracting 780 Shiloh Road Plano, TX 75074 Physicians with questions regarding the amendment can contact UnitedHealthcare’s Network Management Resource Team at (866) 574-6088. UnitedHealthcare Community Plan first launched into the Medi-Cal Managed Care program in Sacramento and San Diego counties beginning October 1, 2017. However, after only a year in the program, UHC recently issued notice that it will no longer provide services to approximately 4,400 Medi-Cal members in Sacramento County, effective November 1, 2018. The notices mailed to Community Plan physicians in July 2018 advise that DHCS will transition all UHC Community Plan members in Sacramento County to other participating Medi-Cal Managed Care plans by November 1. UHC Community Plan members who need assistance in selecting an alternative Medi-Cal health plan or who have questions regarding transitioning to a new plan can be directed to Health Care Options at (800) 430-4263. Physicians with questions regarding the transition should contact UHC Provider Services at (866) 270-5785. August 23, 2018 Managed Care, Medi-Cal, Medicare Commercial Payors, Payor Contracting, Public Payors 0 0 Comment Read More »
Health Net Federal Services experiences significant challenges with TRICARE transition On January 1, 2018, Health Net Federal Services (HNFS) became the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region, serving approximately 2.9 million beneficiaries in 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services (UMVS). The California Medical Association (CMA) has learned that HNFS has experienced implementation issues related to provider contracting and credentialing, beneficiary reassignment to new primary care managers (PCM), and provider directory inaccuracies. The contracting and credentialing issues in California are reportedly related to problems with HNFS staffing turnover and include the following: Completed provider contracts that were not entered into the HNFS system HNFS unable to locate countersigned provider contracts Cases where the contracting or credentialing processes were never completed HNFS shared in recent discussions with CMA that it has identified the providers impacted by the breakdowns and is actively working to expedite completion of the credentialing and contracting processes. Additionally, CMA has learned that as part of the TRICARE transition, DHA allowed TRICARE Prime beneficiaries to receive care from PCMs previously in the UMVS network that were not yet in the HNFS network, without incurring out-of-network fees through June 30. The purpose was to allow HNFS additional time to contract with providers and develop its provider network. When the transition ended, approximately 44,000 California enrollees assigned to 3,800 out-of-network PCMs were reassigned to network PCMs (which includes physicians, nurse practitioners and physician assistants). Although HNFS published information about the end of the transition period in its online provider bulletins, the payor did not directly notify the 3,800 PCMs that their TRICARE Prime patients were being reassigned. HNFS is also experiencing significant provider directory accuracy issues. To address this issue, HNFS has partnered with its parent company, Centene, and LexisNexis to improve the accuracy of its provider directory and expects improvements over the next 30-120 days. What Can Physicians Do? Questions about contract status? Physicians with questions about their contracting and/or credentialing status with HNFS can check the HNFS credentialing status tool at www.tricare-west.com. For additional information, contact Megan Herrera, Director of HNFS Provider Network Management, at (619) 285-3607 or megan.herrera@hnfs.com. Affected by patient reassignment? Physicians affected by the reassignment of patients to a HNFS network PCM who are interested in participating in the HNFS provider network can contact Megan Herrera with HNFS at (619) 285-3607 or megan.herrera@hnfs.com. Once the contracting and credentialing process has been completed, HNFS reports that during July and August it will reassign the affected enrollees back to the original PCM. For more information on PCM reassignments, visit the HNFS Tricare West website. Provider Directory: Practices are also encouraged to check HNFS’ online provider directory to confirm participation status and demographic information. If demographic updates are needed, physicians can submit updates via HNFS’ online tool. If the directory does not accurately reflect participation status, contact HNFS at (844) 866-9378. For more information on the West Region transition issues, see the HNFS FAQ. CMA is working with HNFS to ensure these issues are resolved quickly and adequately. Physicians with questions or concerns can contact HNFS directly at (844) 866-9378 or CMA’s Center for Economic Services at (888) 401-5911. July 24, 2018 General, Managed Care Payor Contracting, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
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 »
Health Net announces significant policy changes to Medicare Advantage and Medi-Cal managed care product lines Health Net recently announced several new payment policies for its Medicare and Medi-Cal lines of business, effective May 16, 2018. The California Medical Association (CMA) is very concerned with the adverse impact these policies would have on physician practices. The new policies would: Reduce reimbursement of evaluation and management (E&M) services when billed with modifier 25 under the following circumstances: When a minor surgical procedure code is reported on the same day as an E/M code by the same physician, payment for the E/M code will be reduced by 50 percent. When a preventative/wellness exam and a problem-oriented E/M are billed during the same encounter, payment for the problem-oriented E/M code will be reduced by 50 percent. Reduce reimbursement for level 4 (CPT 99284) and level 5 (CPT 99285) emergency room services that are billed with what Health Net deems a non-emergent diagnosis to a level 3 (CPT 99283) contracted rate. No longer honor or reimburse for consultation codes (99241-99255), however consultation codes billed will be crosswalked to the appropriate E&M level code for reimbursement. Health Net’s proposed policy change on modifier -25 follows Anthem Blue Cross’ attempt to implement a similar policy, however, due to overwhelming opposition from organized medicine, Anthem rescinded the policy before it was implemented. The Health Net Update states the policy changes “…follow the Centers for Medicare and Medicaid Services (CMS) National Correct Coding Initiative guidelines and will impact providers who are coding outside of fair and appropriate use.” However, only one of the four changes actually aligns with CMS guidelines. CMA has raised concerns with Health Net about these new policies and the payor has committed to engage with CMA on these issues prior to the implementation date in May. Physicians are urged to thoroughly review and assess the impact any proposed modifications to their contract would have on their individual practices. To assist physicians in analyzing the modifier -25 change, CMA has developed a simple worksheet that will help calculate the net financial impact to their practice resulting from this change. The Modifier -25 financial impact worksheet is available free to CMA members. April 5, 2018 General, Managed Care Payor Contracting, Health Nedt 0 0 Comment Read More »
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 »
Anthem dials back modifier 25 payment reduction policy; delays implementation This past fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. The California Medical Association (CMA) quickly jumped into action and coordinated with the American Medical Association (AMA) and the American Association of Dermatologists, along with many other state and specialty organizations, to push back on the proposed change. Due to the overwhelming opposition from organized medicine, Anthem recently announced it would reduce the magnitude of its modifier 25 payment cut from 50 percent to 25 percent, and would delay implementation until March 1, 2018. Anthem will be issuing formal guidance to network physicians communicating these changes within the coming weeks. While this is an improvement on Anthem’s original planned policy, CMA and AMA still strongly oppose this unjustified major reduction in physician payment. CMA will continue to work with AMA and others to seek full retraction of the Anthem policy. CMA has also raised this issue with the California Department of Managed Health Care. In the meantime, physicians are urged to thoroughly review and assess the impact any proposed contract modifications would have on their individual practices. Physicians should also be aware that California law requires health plans and their contracting medical groups/IPAs to provide 45 business days’ advance notice of a material change to a contract, manual, policy or procedure. A change is considered “material” if “a reasonable person would attach importance [to it] in determining the action to be taken upon the provision.” Physicians have the right to terminate an agreement prior to the implementation of a proposed material change. For more information on physicians’ rights and options when a health plan makes a material change to a contract, manual, policy or procedure, see “Contract Amendments: An Action Guide for Physicians.” This resource is available free to CMA members. January 29, 2018 General, Managed Care Contract Amendment, Economic Advocacy, Payor Contracting, Anthem Blue Cross 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 »
