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, ... August 23, 2018 Managed Care, Medi-Cal, Medicare Commercial Payors, Payor Contracting, Public Payors 0 0 Comment Read More »
United Healthcare releases latest Premium Designation physician results United Healthcare (UHC) recently released its latest Premium Designation assessment results to California physicians on July 20. The Premium Program Version 11 results, based on claims data from January 1, 2015, through February 28, 2018, will be released publicly via the payor's online physician directory beginning September 2018. Physicians within 16 specialty categories, encompassing 47 subspecialties including pediatric internal medicine (new for 2018), will again be ranked by UHC on both national and specialty-specific measures for quality and various cost-efficiency benchmarks. Physicians meeting or exceeding these benchmarks will receive a ... August 3, 2018 Managed Care Commercial Payors, Practice Management 0 0 Comment Read More »
United Healthcare Smart Edits go live August 16 UnitedHealthcare (UHC) will implement its Smart Edits program for professional claims for all of its commercial, Medicare Advantage and Community Plans effective August 16, 2018. UHC notified physicians in its 2018 United Healthcare network bulletin that it would implement Smart Edits, a new functionality introduced into the electronic data interchange (EDI) workflow allowing the payor to autodetect claims with potential errors in the claims pre-adjudication phase. Once a potential error has been identified, UHC will notify the physician (via the 277CA report) within 24 hours, returning the claim to ... August 3, 2018 General, Managed Care Commercial Payors, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
CMA joins California Department of Insurance in opposing CVS/Aetna Merger Today, the California Medical Association (CMA) applauded the finding of the California Department of Insurance that the proposed merger between CVS Health and Aetna, Inc. would significantly reduce competition in California’s health insurance market and calls on the U.S. Department of Justice to block the merger from proceeding. In a letter submitted to the U.S. Attorney General and Assistant Attorney General for the Antitrust Division, Insurance Commissioner Dave Jones concluded that the proposed merger would create anti-competitive conditions in the Medicare Part D market, the Pharmacy Benefit Manager services market ... August 2, 2018 General, Managed Care Advocacy, Commercial Payors, Payor Issues and Reimbursement 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, ... 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 »
Has a contracted payor stopped paying claims? The California Medical Association (CMA) has recently received an increased number of calls from physicians reporting concerns that some of the entities with whom they contract may have run into financial difficulties. One of the symptoms of an insolvent health plan, IPA or other payor is the failure to pay claims in a timely manner. Another indication of financial distress is a payor that cuts checks within the statutory timeframes, but does not release the checks in a timely manner. If you are experiencing repeated payment delays, you should investigate the ... August 9, 2017 General Commercial Payors, Payor Insolvency, Payor Solvency, Payors 0 0 Comment Read More »
New law requiring accurate provider directories includes provider obligation to update information On July 1, 2016, a new law will take effect that requires plans and insurers to comply with uniform standards, and provide timely updates, for their provider directories. The law (SB 137) includes multiple components aimed at providing patients with more accurate and complete information to identify which providers are in their payor’s network. Specifically, the law requires: Plans/insurers must offer an online provider directory available to the public, including physicians, without any restrictions or limitations. ... December 7, 2015 Managed Care Network Adequacy, Payor Contracting, Provider Networks, Commercial Payors 0 0 Comment Read More »
