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 »
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 »
CHPI publishes physicians' quality ratings for cycle 2 On March 22, 2017, the California Healthcare Performance Initiative System (CHPI) released its second cycle of physician quality ratings to the public. The ratings can be accessed at CHPI’s newly launched website, CAqualityratings.org, which allows consumers to search ratings on approximately 10,000 California physicians. As previously reported in September 2016, approximately 13,000 physicians in California received their individual quality measurement scores for the second cycle of the CHPI quality rating program. The program rates physicians using claims data from Medicare fee-for-service, Anthem Blue Cross, Blue Shield of California and UnitedHealthcare. ... April 19, 2017 Managed Care, Medicare Managed Care, Medicare, CHPI, Quality of Care 0 0 Comment Read More »
Health Net Federal Services begins TRICARE contracting initiative As previously reported, the Department of Defense awarded the $17.7 billion TRICARE West Region contract to Health Net Federal Services (HNFS). As the recipient of the contract, HNFS will provide managed care services to 2.9 million TRICARE beneficiaries in 19 western states, including California, beginning October 1, 2017. In preparation for the transition, Health Net has sent recruitment notices to physicians soliciting interest in participation in the new Health Net Federal Services (HNFS) West Region network. Included in the recruitment packet is a “Join our Network” form. Physicians interested in ... April 18, 2017 Managed Care Health Net Federal Services, HNFS, Managed Care, TRICARE 0 0 Comment Read More »
Know Your Rights: Managed care contractual protections CMA’s “Know Your Rights” series summarizes vital protections under state and federal law that physicians should be aware of in their dealings with payors. Thanks to legislation sponsored by the California Medical Association (CMA), all health plan contracts with physicians are required to be fair, reasonable and consistent with California law and regulations. Contractual clauses that are specifically prohibited cover the following: Claims filing deadlines that are inconsistent with the law (see "Unfair Payment Practice: Timely Filing Denials") Financial incentives to deny, reduce, limit ... October 13, 2016 Managed Care Know Your Rights, Managed Care, Payor Contracting 0 0 Comment Read More »
California lawmakers unveil bill to tax MCOs and plug $1.1 billion hole in budget California lawmakers on Monday unveiled two identical bills to replace the soon-to-expire tax on managed care organizations (MCO). The bills, ABx2 20 (Bonta) and SBx2 15 (Hernandez), are the product of 14 months of negations with MCOs. These bills are supported by the California Association of Health Plans, with most member plans either supportive or neutral. The current MCO tax will expire this summer if legislators cannot agree on a replacement. Since 2005, the state has taxed MCOs and used the money to cover the costs of the Medi-Cal program. ... February 16, 2016 Managed Care, Medi-Cal Medi-Cal, State Legislation, Managed Care, Managed Care Organization (MCO) 0 0 Comment Read More »
California Medical Association responds to unveiling of Governor Brown's proposed 2016-17 state budget Sacramento – Steve Larson, M.D., president of the California Medical Association (CMA), representing over 41,000 physicians statewide, issued the following statement in response to the unveiling of Governor Brown’s proposed 2016-17 state budget released this morning: “We are pleased to see the Governor is committed to working with the legislature and health plans to find a solution to the MCO tax. Without that, a gaping hole would exist in the state’s Medicaid (Medi-Cal) fund that would have devastating impacts on patients across the state. “Ensuring that Medi-Cal is better funded ... January 15, 2016 General, Managed Care, Medi-Cal Managed Care, Medi-Cal, Save Lives California, Tobacco Tax, California State Budget 0 0 Comment Read More »
Changes to Anthem Blue Cross reimbursement policies and claims software 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 July 1, 2015. Because of these changes, physicians may notice a difference in how certain codes and code pairs are adjudicated. Along with the notice, Anthem provided a comprehensive grid outlining the new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies. The changes include additions to the types of service Anthem will consider bundled ... May 15, 2015 Managed Care Billing/Coding, Insurance, Managed Care, Anthem Blue Cross 0 0 Comment Read More »
Anthem system error results in missing remittances In early February, the California Medical Association (CMA) began receiving reports from practices of missing Anthem Blue Cross remittances. CMA escalated the issue to the payor and has since learned that a system issue is to blame for the missing electronic remittance advices (ERA). Anthem reports that the problem began in mid-December and affected ERAs for exchange/mirror and Federal Employee Program (FEP) claims. Somehow, the ERA function was turned off in the Anthem system for these product types. So, while practices received the money for the affected claims through ... March 17, 2015 Managed Care Anthem Blue Cross, Insurance/Reimbursement, Managed Care 0 0 Comment Read More »
United Healthcare to host webinars about its Premium Designation Program for contracted physicians At the request of the California Medical Association, United Healthcare (UHC) is inviting physicians and practice administrators to attend a special webinar presentation about its Premium Designation program in California. The webinars will be offered in mid-November and will provide an overview on the background and methodologies of the Premium Designation program and allow physicians an opportunity to ask specific questions they may have. The webinars will take place on the following dates and times. Participants will need to register with UHC prior to attending. Click the registration links below ... November 10, 2014 Managed Care Insurance/Reimbursement, Managed Care, Webinars, United Healthcare 0 0 Comment Read More »
