CMA urges CMS to recalculate practice expense data to reflect California's higher practice costs As required by law, at least every three years the Centers for Medicare and Medicaid Services (CMS) adjusts payments under the Medicare physician fee schedule to reflect local differences in practice costs. In the proposed 2017 Medicare physician fee schedule, CMS made nationwide updates to the geographic practice cost indices (GPCI) based on new wage, rent and malpractice expense data. Unfortunately, according to CMS, the malpractice and practice expense GPCIs went down in nearly every region of California, which would result in a 0.48 percent GPCI payment reduction in all ... September 22, 2016 Managed Care, Medicare Fee Schedule, Geographic Practice Cost Index, GPCI, Medicare, Regulatory Advocacy, Centers for Medicare and Medicaid Services 0 0 Comment Read More »
Have you received a request to confirm provider directory information from BetterDoctor? The California Medical Association (CMA) has received an increasing number of inquiries over the past few weeks from practices concerned about the validity of requests for information from a company called BetterDoctor. SB 137, the new provider directory accuracy law, took effect July 1. The new law requires payors to ensure that their physician directories are accurate and up-to-date. BetterDoctor is a vendor working on behalf of 10 plans on a pilot project to ensure the accuracy of their physician directories, as required under the new law. Practices are encouraged ... September 22, 2016 Managed Care Health Insurance Exchange, Provider Directories, Provider Directory Accuracy Law, Exchange Plans 0 0 Comment Read More »
United Healthcare fails to provide proper notification on rollout of clinical data submission protocol The California Medical Association (CMA) is concerned that United Healthcare (UHC) failed to properly notify physicians before implementation of its Clinical Data Submission Protocol. Although California law (California Insurance Code §10133.65 and Health & Safety Code §1375.7) requires payors to provide contracted physicians with the 45 business days’ advance notice of any material contracting changes, UHC's only notification to physicians about this new protocol was in its Network Bulletin. First introduced in 2015, the program originally targeted only Medicare benefit plans and required physicians to submit all laboratory test ... September 13, 2016 Managed Care, Medicare United Healthcare, Medicare 0 0 Comment Read More »
Blue Shield to shut down for four days in September Last week, Blue Shield of California announced that it would close its doors for the four days after Labor Day to reduce its payroll-related liabilities, citing losses in the Covered California health insurance exchange. The shutdown, lasting from September 5 to 9, will affect most of its 6,000 employees. The company claims this will save it an estimated $4 million. Some Blue Shield customer service representatives and medical services staff are still expected to be on the job during that period. The California Medical Association has also confirmed that while the ... August 25, 2016 Managed Care Blue Shield 0 0 Comment Read More »
UHC to require prior authorization for select outpatient surgical procedures As indicated in its July 2015 Network Bulletin, United Healthcare (UHC) will begin requiring prior authorization for certain surgical procedures done in a hospital outpatient setting effective October 1, 2016. The new prior authorization requirement includes procedure codes in cardiovascular, cosmetic and reconstruction, ophthalmology, and ENT (ear, nose and throat) specialties. Prior authorization will not be required to perform the identified procedures if done in an in-network ambulatory surgery center. For a complete listing of procedures requiring prior authorization, physicians can access the Prior Authorization for Outpatient Surgical Procedures FAQ ... August 9, 2016 Managed Care United Healthcare, Preauthorization 0 0 Comment Read More »
Health Net Federal Services awarded Tricare contract beginning late 2017 Health Net Federal Services (HNFS) has been awarded the contract for managed care support (MCS) for the Tricare West Region, replacing the current MCS contractor, United Military and Veteran Services. Under the $17.7 billion contract, HNFS will provide direct medical care and administrative support services to Tricare beneficiaries throughout the 19 state western region, which includes California. According to HNFS, a nine-month transition period is expected, with an anticipated start of health care delivery sometime in mid-2017. HNFS has been the managed care contractor for the Tricare North Region since ... August 9, 2016 Managed Care Tricare, Health Net 0 0 Comment Read More »
Blue Shield implements system fix to correctly pay HPV9 claims Under the Affordable Care Act, health plans are required to provide “first dollar” coverage for preventive services. This means that the plan cannot apply patient cost sharing, such as copays, coinsurance or deductibles, to these services. However, in September 2015, the California Medical Association (CMA) was alerted by a physician practice that Blue Shield of California was applying patient cost sharing when it processed HPV9 claims with CPT code 90651. CMA escalated the issue to Blue Shield and has been working with the payor since then to correct the ... August 9, 2016 Managed Care Affordable Care Act, Blue Shield, ACA 0 0 Comment Read More »
Anthem Blue Cross announces changes to reimbursement policies and claims software effective October 1, 2016 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 October 1, 2016, with the exception of policies for Multiple Diagnostic Ophthalmology Procedures (CA–0050) and Multiple Diagnostic Cardiovascular Procedures (CA-0051), which become effective on October 17, 2016. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated. The notice included a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules, ... August 9, 2016 Managed Care Anthem Blue Cross 0 0 Comment Read More »
Covered California announces plan offerings for 2017 Covered California, the state marketplace for health insurance under the Affordable Care Act, recently announced the qualified health plans that were approved to offer coverage in the exchange market for 2017. All of the plans that offered coverage in 2016 will continue to do so in 2017. Three of the plans will also be expanding into new regions this year. Molina is expanding its HMO coverage into Orange County (region 18) through delegated relationships with Monarch and Heritage Network ... August 8, 2016 Managed Care Affordable Care Act, Covered California, Exchange Plans, Molina, Oscar, ACA, Kaiser Permanente 0 0 Comment Read More »
Covered California announces sharp rate hike Covered California has announced an average 13.2 percent hike in insurance premiums for 2017, a sharp increase that is likely to reverberate nationwide in an election year. The California Medical Association (CMA) is concerned the premium increases may hinder the ability of some patients to obtain insurance and access necessary medical treatment. The rise in Covered California premium rates was driven largely by its two biggest insurers, which account for about half of its enrollment. Blue Shield of California said its average rate hike is 19.9 percent, the biggest statewide ... August 5, 2016 Managed Care Covered California, Exchange Plans, Health Insurance Exchange, Affordable Care Act 0 0 Comment Read More »
