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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 ...

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 ...

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 ...

Blue Shield CEO addresses California physicians on digital health efforts

Paul Markovich, president and CEO of Blue Shield California, on Friday addressed the California Medical Association’s (CMA) Board of Trustees, to discuss the payor’s initiatives to develop new health care technologies including sharable digital patient records and electronic claims among other initiatives. Markovich told the CMA trustees that Blue Shield was seeking to reduce administrative costs significantly over the next three years to help support investment in numerous digital efforts. Blue Shield and CMA announced in June a new, multi-year collaboration to develop and support a new health care model that ...

Proposed policy, payment, and quality provisions changes to the Medicare Physician Fee Schedule

On July 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 Medicare Physician Fee Schedule and Quality Payment Program proposed rule with comment period.  This is the first year the two rules have been combined.  CMS also issued QPP and PFS fact sheets on the proposed rule.  CMS is accepting comments on the proposed rule through September 10, 2018. The final rule is expected to be released in early November.    American Medical Association staff is continuing to conduct a detailed review of the proposed rule and ...

Health Net Federal Services experiences significant challenges with TRICARE transition

On January 1, 2018, Health Net Federal Services (HNFS) became the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region, serving approximately 2.9 million beneficiaries in 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services (UMVS). The California Medical Association (CMA) has learned that HNFS has experienced implementation issues related to provider contracting and credentialing, beneficiary reassignment to new primary care managers (PCM), and provider directory inaccuracies. The contracting and credentialing issues in California are reportedly related ...

DHCS requires enrollment for all Medi-Cal managed care providers

In January 2018, the California Department of Health Care Services (DHCS) began requiring that all Medi-Cal managed care providers be enrolled through the Medi-Cal program. Medi-Cal managed care plans have the option to develop and implement a managed care physician screening and enrollment process that meets federal requirements, or they may direct their network physicians to enroll through the DHCS fee-for-service (FFS) enrollment portal. (Enrolling through DHCS does not obligate managed care network providers to also see FFS patients.) Some physicians have already reported receiving notices from Medi-Cal managed care ...

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, ...

State budget includes 10 new CPT codes eligible for supplemental tobacco tax payments

Governor Jerry Brown last week signed a $139 billion California budget for the 2018-2019 fiscal year. The budget continues the Administration’s commitment to using the Proposition 56 tobacco tax funding to provide supplemental payments for Medi-Cal providers, with $500 million in tobacco tax funds allocated to improve provider reimbursement through supplemental payments. The total funding for provider payments is approximately $1.3 billion. DHCS plans to allocate the tobacco tax funds to increase payments for a total of 23 CPT codes, which includes 10 new preventive CPT codes. The supplemental rate ...

Blue Shield implements system fix for AB 72 claims

Last year, the California Medical Association (CMA) worked with Blue Shield of California to correct two issues affecting accurate payment of claims subject to the state’s new out-of-network billing and payment law (AB 72). The issues were identified as being due to manual claim processing errors, because the payor had not yet updated its system to allow automated processing of claims subject to AB 72. Blue Shield recently announced it was implementing a system update on June 28, 2018, that will allow claims subject to AB 72 to be processed ...