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UnitedHealthcare to implement outpatient advanced radiology policy

Effective January 1, 2019, UnitedHealthcare (UHC) will require prior authorization for certain advanced imaging procedures when performed in the outpatient hospital setting. As highlighted in the UnitedHealthcare Network Bulletin October 2018, certain magnetic resonance imaging, magnetic resonance angiography and computed tomography imaging procedures will now be subject to a site of care review when performed in the outpatient hospital under UHC’s Outpatient Radiology Notification/Prior Authorization Protocol. Site of care reviews will not be done as part of the prior authorization process if a procedure will be performed in a free-standing diagnostic ...

CDPH hosts webinar on California Parkinson's Disease Registry

On July 1, 2018, the California Department of Public Health (CDPH) launched the California Parkinson’s Disease Registry, a statewide population-based registry that will be used to measure the incidence and prevalence of Parkinson's disease.  MD’s, DO’s, PA’s, and NP’s who diagnose or treat Parkinson’s disease patients are required to report. The first deadline for data submission is March 29, 2019, for cases encountered during the first quarter the law was in effect (July 1 to September 30, 2018).  Details on the reporting obligation can be found in the Implementation Guide, ...

CMA Applauds the Enactment of Federal Opioid Legislation

The California Medical Association (CMA) applauded the enactment of H.R. 6 – a sweeping bipartisan bill that addresses nearly every component of the national opioid epidemic. The legislation would improve access to preventive services, opioid use disorder treatment programs, medication-assisted treatment (MAT) and non-opioid therapies, including mental health services. It would lift restrictions on using telemedicine for treatment of substance use disorders. To address the escalation in overdose deaths, it would also strengthen law enforcement efforts to crack down on international shipments of illicit drugs such as fentanyl. H.R. 6 ...

Medicare publishes 2018-2019 influenza vaccine pricing

The Center for Medicare and Medicaid Services (CMS) recently published an update on Medicare’s influenza vaccine payment allowances and effective dates for the 2018-2019 flu season. The Medicare Part B payment allowance limits for seasonal influenza and pneumococcal vaccines are calculated at 95 percent of the average wholesale price. Payment allowances and effective dates for the 2018-2019 flu season:​ Code Labeler Name Drug Name Payment Allowance Effective Dates 90653 Seqirus ...

Last day to change your Medicare participation status for 2019 is December 31

Once again, it’s time for physicians to decide if they want to make changes to their Medicare participation status. Physicians have until December 31, 2018, to make changes for the 2019 participation year. As always, physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely. Details on each of the three participations options are as follows: A participating physician must accept Medicare-allowed charges as payment in full for all Medicare patients.   A non-participating provider can make assignment decisions on ...

First-ever TRICARE open enrollment begins November 12

Beginning November 12 and running through December 10, 2018, TRICARE will initiate its first ever open enrollment period for beneficiaries to enroll in or change their TRICARE Prime or TRICARE Select health plan coverage. Beneficiaries already enrolled who want to continue with their current plan without changes do not need to do anything. Any changes made during the 2018 open enrollment will be effective January 1, 2019. Outside of open enrollment, beneficiaries enrolled in Prime or Select will only be able to make a plan change if they have ...

L.A. Care partially rescinds recoupment requests

Between June and August of this year, L.A. Care issued a large number of overpayment requests to physicians. According to L.A. Care, it was requesting refunds on overpaid Medi-Medi claims. However, some of the requests were for very old claims, dating back to 2012. The California Medical Association (CMA) raised concerns with L.A. Care about the timeliness of some of the refund requests, as California’s Knox Keene act limits plans’ ability to request refunds to 365 days from the date of payment, except in cases of fraud or misrepresentation. After ...

Some Medi-Cal managed care plans slow to distribute Prop 56 funds

In May, the California Department of Health Care Services (DHCS) distributed the Proposition 56 supplemental funds for FY 2017-2018 to the Medi-Cal managed care plans. At the California Medical Association’s request, DHCS specified that plans must distribute the funds to providers within 90 days. However, the 90-day window ended August 31 and CMA has received complaints from physicians that some plans have still not issued supplemental payments. The supplemental payments are a result of the California Health Care, Research and Prevention Tobacco Tax Act of 2016 (Prop 56), which created ...

Apple Valley pediatrician, Damodara Rajasekhar, M.D., San Bernardino pediatrician, honored with CMA membership award

Apple Valley pediatrician Damodara Rajasekhar, M.D., has been named the 2018 recipient of the California Medical Association (CMA) Dev A. GnanaDev, M.D., Membership Award, which recognizes a special or unique effort toward membership recruitment. The award was announced today at CMA’s annual House of Delegates in Sacramento. Dr. Rajasekhar this year played a major role in continuing CMA’s partnership with Loma Linda University Medical Center, leading to a membership renewal for 440 Loma Linda physicians. “[Dr. Rajasekhar was] the vital spark that reignited the flame, creating an alliance between one of ...

IEHP completes termination of Vantage contract; three plans extend termination dates

The California Medical Association (CMA) has confirmed that Inland Empire Health Plan (IEHP) completed its contract termination with Vantage on August 31, 2018. IEHP transitioned its 273,000 covered lives to the following delegated groups: Receiving Provider Group Number of Enrollees Alpha Care Medical Group 80,190 La Salle Medical Associates 74,428 IEHP Direct 74,176 ...