Anthem Blue Cross terminates Medicare Advantage agreement with Brown and Toland Effective October 1, 2017, Anthem Blue Cross will terminate its contract with Brown & Toland Physicians for its Medicare Advantage product. The termination will affect approximately 1,900 Medicare Advantage enrollees in San Francisco. Affected patients will be reassigned to Asian American Medical Group, Jade Health Care Medical Group or Imperial Health Holdings Medical Group. The termination was reportedly due to a failure to reach a contractual agreement with Brown & Toland. Physicians with questions can contact Brown & Toland representative Stephanie Mamane at (415) 972-4282 or smamane@btmg.com. August 9, 2017 Managed Care, Medicare Anthem Blue Cross, Medicare Advantage, San Francisco Medical Society 0 0 Comment Read More »
Health plans begin transitioning patients from troubled Nivano The California Medical Association (CMA) has learned that two health plans—Blue Shield and UnitedHealthcare (UHC)—have recently terminated their delegated agreements with Nivano Physicians Medical Group and are in the process of transferring patients from Nivano to alternative networks. Nivano, also known as Northern California Physicians Medical Group with enrollees in Placer, Nevada, Sacramento, Yuba and Colusa counties, is currently on a corrective action plan with the Department of Managed Health Care (DMHC) for failure to meet financial solvency criteria. CMA has also received a surge of complaints about delays in ... August 9, 2017 Managed Care Blue Shield, UnitedHealthcare 0 0 Comment Read More »
Updated payor profiles for 2017 now available The California Medical Association’s (CMA) Center for Economic Services is publishing updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical directors, provider relations, and other key contacts. Don’t waste your time searching the internet for this information – members can download CMA’s Payor Profiles free of charge ... August 1, 2017 CMA, Managed Care, Medi-Cal, Medicare Aetna, Anthem Blue Cross, Blue Shield, Cigna, Health Net, Insurance, Medi-Cal, Medicare, Noridian, Payor, Payor Profiles, Running a Practice, UnitedHealthcare 0 0 Comment Read More »
UnitedHealthcare to issue new Premium Designation physician results In its June Network Bulletin, UnitedHealthcare (UHC) announced that the next iteration of its Premium Designation assessment results will be sent to physicians in early July. These results will be released publicly via the payor's online physician directory beginning September 6, 2017. Physicians within 16 specialties (allergy, cardiology, ENT, endocrinology, family medicine, gastroenterology, general surgery, internal medicine, nephrology, neurology, neurosurgery, OB/GYN, pediatrics, pulmonology, rheumatology and urology) and their 46 credentialed sub-specialties will again be ranked by UHC on both national and specialty-specific measures for quality and various cost-efficiency benchmarks. UHC says ... July 21, 2017 Managed Care United Healthcare 0 0 Comment Read More »
Blue Cross adds 3D mammography to preventative care coverage Anthem Blue Cross recently updated its preventive coverage policy on screening digital breast tomosynthesis (DBT or 3D mammography). Beginning with June 6, 2017, dates of service for individual, small group and large group health plans, 3D mammography for screening purposes will be covered at 100 percent, with no member cost share (copayments, deductibles or coinsurance). Anthem National Account plans will be updated to reflect this update beginning August 1, 2017. This follows a February 2017 change Anthem made to archive its prior policy on 3D mammography, which deemed the procedure ... July 21, 2017 Managed Care Anthem Blue Cross 0 0 Comment Read More »
UnitedHealthcare to implement new drug testing reimbursement policy UnitedHealthcare has advised that it will implement a new drug testing reimbursement policy for commercial members effective for dates of service on or after September 1, 2017. The new policy will only allow one Presumptive Drug Class procedure per drug class (codes 80305, 80306 and 80307) per member, per date of service, whether submitted by the same or different provider. The policy will also only allow one Definitive Drug Class procedure per drug class (codes G0480, G0481, G0482, G0483 and G0659) per member, per date of service, whether submitted ... July 21, 2017 Managed Care Drug Testing, UnitedHealthcare 0 0 Comment Read More »
Have you received a termination notice from Blue Cross recently? The California Medical Association (CMA) has heard from several physicians who have received unexpected termination notices from Anthem Blue Cross. The notices, which specify no cause for termination, appear directed only to physicians who refer to out-of-network ambulatory surgical centers. If you have recently received a similar termination notice from Anthem Blue Cross, CMA wants to hear from you. Please contact CMA's Reimbursement Helpline at (888) 401-5911 or economicservices@cmanet.org. July 21, 2017 Managed Care Anthem Blue Cross 0 0 Comment Read More »
Significant improvements in 2018 MACRA rule The Centers for Medicare & Medicaid Services (CMS) has issued a proposed rule that would make changes in the second year of the Quality Payment Program as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Though not perfect, the California Medical Association (CMA) is pleased that CMS has listened to physician feedback and has made changes that will significantly reduce the administrative burdens on physicians, particularly for small and rural practices. Under the proposed rule, 2018 will be another transition year like 2017. This means that physicians ... July 21, 2017 Managed Care, Medicare CMA, MACRA, Medicare, Regulatory Advocacy 0 0 Comment Read More »
Child Health and Disability Prevention code and claim form conversion effective July 1 The California Department of Health Care Services (DHCS) is currently transitioning Child Health and Disability Prevention (CHDP) program billing processes to be compliant with HIPAA standards for national health care electronic transactions and code sets. Rather than billing on the CHDP Confidential Screening/Billing Report (PM 160) claim form, claims will be submitted using CPT codes on the CMS 1500 or UB-04 claim forms or equivalent electronic claim transactions. The transition, effective for dates of service on or after July 1, 2017, affects claims for Medi-Cal Early and Periodic Screening, Diagnosis ... June 22, 2017 Managed Care, Medi-Cal Child Health and Disability Prevention Program, Department of Health Care Services, DHCS, HIPAA, Medi-Cal, CHDP 0 0 Comment Read More »
CDI issues instructions for "average contracted rate" under new out-of-network billing and payment law On July 1, 2017, a new law (AB 72, 2016) will take effect that changes the billing practices of non-contracted physicians providing non-emergent care at in-network facilities including hospitals, ambulatory surgery centers and laboratories. The law is designed to reduce unexpected medical bills when patients go to an in-network facility but receive care from an out-of-network doctor. While patients with out-of-network benefits can consent to treatment from out-of-network providers, absent a valid consent form, health plans and insurers are required to reimburse out-of-network physicians at an interim payment rate. The ... June 22, 2017 Managed Care Out of Network Care, AB 72 0 0 Comment Read More »
