Updated payor profiles now available The California Medical Association’s (CMA) Center for Economic Services has published updated profiles on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, United Healthcare, 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 ... July 20, 2015 Managed Care Payor Profiles 0 0 Comment Read More »
CMS announces changes to make Medicare ICD-10 transition less disruptive for physicians The Centers for Medicare & Medicaid Services (CMS) announced that it will provide a one-year grace period during which it will allow for flexibility in the claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set. The ICD-10 implementation date of October 1, 2015, has not changed. The changes announced include: Claim denials: Medicare review contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of codes ... July 13, 2015 Managed Care, Medicare CMS, ICD-10, Medicare, Centers for Medicare and Medicaid Services 0 0 Comment Read More »
Anthem Blue Cross announces further changes to reimbursement policies and claims software Anthem Blue Cross recently notified physicians of additional upcoming changes to its reimbursement policies and claims editing software, ClaimsXten. The additional changes, scheduled to go into effect on September 14, 2015, come less than 90 days after Anthem’s most recent set of changes were implemented in July, and less than a month prior to the implementation of ICD-10. Anthem states that the additional changes are necessary to bring its claims editing system in line with correct coding guidelines. Anthem did not provide a detailed listing of all the incorporated changes; ... July 6, 2015 General, Managed Care Anthem Blue Cross, Insurance/Reimbursement 0 0 Comment Read More »
Anthem Blue Cross begins medical chart reviews in July In July, Anthem Blue Cross will begin chart reviews on enrollees who purchased Affordable Care Act (ACA)-compliant plans in either the individual and small group insurance markets (both on and off the exchange, known as “Covered California”). The records requests are a result of the commercial risk adjustment program created by ACA Section 1343. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to ... July 6, 2015 General, Managed Care Affordable Care Act, Anthem Blue Cross, Covered California, ACA, Health Insurance Exchange 0 0 Comment Read More »
CMS rule reduces Meaningful Use burdens; CMA advocates for more change On June 15, the California Medical Association (CMA) submitted comments to the Centers for Medicare and Medicaid Services (CMS) on proposed rules modifying Stage 1 and Stage 2 Meaningful Use criteria of the federal electronic health records (EHR) incentive programs. Under the federal EHR incentive programs, qualifying Medicare and Medi-Cal providers are eligible to receive incentive payments for adopting and demonstrating “Meaningful Use” of certified health information technology. The proposed rule aligns Stage 1 and Stage 2 Meaningful Use objectives and measures for 2015 through 2017 with proposed Stage 3 ... June 26, 2015 Managed Care, Medi-Cal, Medicare CMS, EHR, Electronic Health Record, HIT, Meaningful Use 0 0 Comment Read More »
What is commercial risk adjustment? Over the past few months, CMA has received several calls from practices who had received requests for medical records from various payors stating the records are needed for “risk adjustment.” The records requests are a result of the commercial risk adjustment program created by Section 1343 of the Affordable Care Act. The primary goal of the risk adjustment program is to spread the financial risk borne by payors more evenly in order to stabilize premiums and provide issuers the ability to offer a variety of plans to meet the ... June 26, 2015 General, Managed Care Payors, Medical Records 0 0 Comment Read More »
Anthem Special Investigations Unit may be recouping beyond statutory timeframe In 2011, the California Medical Association (CMA) raised concerns with Anthem’s attempts to recoup money from physicians beyond the statutory timeframe. Through its Special Investigations Unit (SIU), Anthem was pursuing physicians for refunds of payments made outside of the 365-day period allowed by California law. That law permits recoupment of claims older than a year only if the payment was made based on fraud or misrepresentation. CMA determined that Anthem was employing a definition of “misrepresentation” that was much broader than what is allowed under law. CMA thus filed ... June 26, 2015 General, Managed Care Department of Managed Health Care, Recoupment, Anthem Blue Cross 0 0 Comment Read More »
CMS to issue new Medicaid managed care rules for comment For the first time since 2002, the Obama administration has announced that it will propose new federal regulations for Medicaid managed care. The Centers for Medicare and Medicaid Services (CMS) is slated to issue a Notice of Proposed Rulemaking sometime in 2015. Industry stakeholders have already submitted input and recommendations to CMS to consider in the final drafting of the new rules. Indications from those who have already commented on agency drafts are that the new rules will address rate setting, stronger beneficiary protections and easing beneficiary transitions between Medicaid ... May 26, 2015 Managed Care, Medi-Cal CMS, Long Term Care, Medi-Cal, Centers for Medicare and Medicaid Services 0 0 Comment Read More »
United Healthcare to deactivate inactive physician TINs as part of provider directory cleanup Beginning August 1, 2015, United Healthcare (UHC) will initiate a cleanup of its participating provider database and directory. Participating physicians who have not submitted a claim to UHC for a period of one year will be deemed to have voluntarily ceased participation in the UHC physician network; United will initiate a termination of the physician agreement. UHC will contact impacted providers to advise of the termination and to clarify any concerns from the physician. The California Medical Association has inquired about when and how physicians will be notified. Additionally, ... May 21, 2015 General, Managed Care United Healthcare 0 0 Comment Read More »
United Healthcare to alter Premium Designation criteria The California Medical Association (CMA) has learned that United Healthcare (UHC) has altered the criteria for meeting the physician cost efficiency component of its Premium Designation program. UHC will now designate a physician as “Cost Efficient” when he or she has met the episodic cost benchmark, even if the physician did not achieve the population cost benchmark. The change only impacts those physician specialties that are evaluated on both population cost and episode cost, which include: Family medicine, Internal medicine ... May 18, 2015 General, Managed Care United Healthcare 0 0 Comment Read More »
