Patient outcomes shortchanged by prior authorization More than nine in 10 physicians (92 percent) say that prior authorizations programs have a negative impact on patient clinical outcomes, according to a new physician survey by the American Medical Association (AMA). The survey results further bolster a growing recognition across the entire health sector that prior authorization programs must be reformed. According to the AMA survey, which examined the experiences of 1,000 patient care physicians, nearly two-thirds (64 percent) report waiting at least one business day for prior authorization decisions from insurers—and nearly a third (30 percent) said ... April 5, 2018 Managed Care American Medical Association, Managed Care 0 0 Comment Read More »
New Anthem anesthesia policy can have blinding consequences A policy change made by health insurer Anthem, Inc. could result in increased risk for many patients – up to and including blindness – if not immediately rescinded, according to physicians’ groups. The California Academy of Eye Physicians and Surgeons (CAEPS) and the California Society of Anesthesiologists (CSA) have sent letters to Anthem Inc. requesting that they immediately rescind a new policy that deems Monitored Anesthesia Care (MAC) “not medically necessary” during “routine” cataract surgery – a move seen as endangering patients. These were followed up with complaints to the ... February 5, 2018 General, Managed Care Advocacy, Anesthesiology, Anthem Blue Cross, California Academy of Eye Physicians and Surgeons, California Society of Anesthesiologists, Ophthalmology 0 0 Comment Read More »
CMA calls for investigation into Anthem policy restricting use of sedation during cataract surgery On December 27, 2017, Anthem Blue Cross implemented a clinical guideline that restricts the use of intravenous anesthesia to sedate patients during cataract surgery. The California Medical Association (CMA) believes this drastic change in policy will cause significant patient safety concerns and put patients at risk of serious complications, including blindness. The new policy, “Anesthesia for Cataract Surgery,” deems intravenous anesthesia (including moderate sedation, monitored anesthesia care or general anesthesia) not medically necessary, except in very narrow circumstances. Anthem patients wishing to have any form of intravenous anesthesia during the ... February 5, 2018 General, Managed Care Anthem Blue Cross, Anesthesiology, Contract Amendment, Medical Necessity, Opthalmology 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, ... 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 »
CMS announces new voluntary bundled payment model The Centers for Medicare and Medicaid Services (CMS) has announced a new voluntary bundled-payment model. Called the Bundled Payments for Care Improvement (BPCI) Advanced Model, it will be considered an advanced alternative payment model (APM) under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). This new, voluntary model comes less than two months after the CMS eliminated two mandatory bundled-payment models created during the Obama administration. MACRA’s Quality Payment Program (QPP) created two tracks for physician payment – the Merit-Based Incentive Payment System (MIPS) and Advanced APM track. Under ... January 30, 2018 Managed Care, Medicare Alternative Payment Models (APM), MACRA, Medicare, Merit-Based Incentive Payment System (MIPS) 0 0 Comment Read More »
DMHC orders 600,000 patients transferred from troubled medical group 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. The health plans affected by this order must transfer all EHS patients to different health care providers by early February 2018. The plans were ... January 30, 2018 General, Managed Care, Medi-Cal Department of Managed Health Care, Managed Care, Medi-Cal 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 ... January 29, 2018 General, Managed Care Contract Amendment, Economic Advocacy, Payor Contracting, Anthem Blue Cross 0 0 Comment Read More »
Do you see TRICARE patients? Check out CMA's new toolkit to assist physicians with the transition On January 1, 2018, Health Net Federal Services (HNFS) will begin providing managed care services to 2.9 million TRICARE beneficiaries in the 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services. In preparation for the transition, the California Medical Association (CMA) has prepared a TRICARE Transition Guide to help physicians understand the impact the transition will have on their practices. The guide is available free to members in the CMA resource library. December 28, 2017 Managed Care Health Net, TRICARE 0 0 Comment Read More »
Anthem still not complying with AB 72 interim payment rules, physicians report The California Medical Association (CMA) has continued to receive reports from physician offices that Anthem Blue Cross is not paying the “interim payment” as required under California’s new law (AB 72) limiting out-of-network billing for covered, non-emergent services performed at in-network facilities. CMA has also received reports that Anthem representatives have advised some physicians that its Covered California EPO products are not subject to AB 72, which is incorrect. The new law requires fully insured commercial plans and insurers to make “interim payments” to non-contracted physicians for non-emergent services performed ... December 28, 2017 Managed Care Anthem Blue Cross, AB 72, Economic Advocacy, Out of Network Care 0 0 Comment Read More »
UnitedHealthcare delays consultation services payment policy change UnitedHealthcare (UHC) announced in its October 2017 Network Bulletin that it will indefinitely delay changes to its consultation services payment policy, which would have discontinued reimbursement for CPT codes 99241-99245 and 99251-99255. Citing alignment with a policy implemented by the Centers for Medicare and Medicaid Services, and in response to misuse of consultation service codes, UHC had previously announced that it would no longer reimburse consultation services for commercial product lines effective October 1, 2017. In lieu of a consultation service code, physicians would have been required to bill utilizing ... October 19, 2017 General, Managed Care Consultation Codes, UnitedHealthcare 0 0 Comment Read More »
