Source: http://www.cmanet.org/cpr/cpr-archives/2012/october-2012/
Timestamp: 2017-11-24 03:33:32
Document Index: 196748520

Matched Legal Cases: ['§1300', '§1300', '§10133', '§1300', '§10133', 'art 1']

October 2012 - 2012 - California Medical Association
CMA Practice Resources (CPR) is a free email bulletin from CMA's Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability.
Palmetto GBA loses Medicare MAC contract
Did you know that the new contracts being offered by Blue Shield may lock you into California Health Benefit Exchange networks?
Physicians being recruited to participate in the rural expansion of Medi-Cal managed care program
CMA publishes guide for physicians terminated by Aetna for out-of-network referrals
CMA and DHCS to provide education to physicians who see dual-eligible patients with adult day care services
CMA general counsel to appear on Northern California Healthcare Conference panel
Ask the expert: My claim was denied for timely filing. Do I have any recourse?
Coalition of state and specialty societies issue joint letter disputing Aetna’s additional accreditation requirements
Meet your CMA advocate: Melanie Neumeyer
The Coding Corner: Separately billing in E/M visits
Reminder: Anthem Blue Cross changes to payment policies and claims editing software to become effective December 8
NCCI October updates
Medicare Part B physical therapy pre-approval
The Centers for Medicare & Medicare Services (CMS) announced in September that Noridian Administrative Services (NAS) has been named the new Medicare Administrative Contractor (MAC) for Medicare Parts A and B in California, Nevada, and Hawaii, as well as the U.S. territories of American Samoa, Guam and the Northern Mariana Islands (Jurisdiction E, previously called Jurisdiction 1).
Jurisdiction E includes over 3.5 million Medicare fee-for-service beneficiaries, 500 Medicare hospitals and 86,500 physicians. MACs process Part A and Part B claims and perform other critical Medicare operational functions, including enrolling, educating and auditing Medicare providers.
It is not yet clear whether Palmetto GBA plans to appeal the decision. If there is an appeal, the earliest the handover could take place would be mid-to-late 2014.
CMA will work with CMS and the new contractor to help minimize any disruption to physicians and patients.
Blue Cross recently conducted two studies of physician coding, one on new and established evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier -25. The analyses involve claims paid by Blue Cross between May 1, 2011 and April 30, 2012.
Physicians who, according to the insurer, billed these codes at "considerably higher" frequencies, are receiving letters that contain their individual results. The letters—sent by EquiClaim, the company contracted to perform the studies— advise physicians that their use of these high-level codes is greater than others in their specialty and warns that their usage will continue to be monitored. The notices also include information about Blue Cross's relevant billing policies.
Blue Cross advises that approximately 5,000 notices total will be sent to physicians (1,826 for modifier 25 issues and 3,216 for E/M issues). The notices are not audit letters and do not ask for medical records at this time. They do, however, state that if subsequent analyses continue to show excessive usage, EquiClaim may request medical records and, if appropriate, request refunds if the documentation does support the coding.
Physicians who wish to dispute the Blue Cross findings may do so in writing by submitting an appeal to Anthem Blue Cross c/o EquiClaim, P.O. Box 5037, Naperville, IL 60567-5037.
EquiClaim will also be performing studies on physician usage of modifiers -24, -57 and -59 at a later date.
While Blue Cross first announced its CPT coding compliance program in November 2011, they have, at the California Medical Association's urging, modified the program significantly. Although the insurer had originally planned to audit all modifiers at the same time, it has agreed to stagger the studies. Blue Cross has also agreed to modify the program to first provide education on usage and coding criteria, rather than a punitive and administratively burdensome audit as originally intended.
CMA appreciates Blue Cross’s willingness to approach the issue from an educational perspective rather than fostering the perceived impression that physicians are intentionally doing something wrong.
Questions about the analyses can be directed to EquiClaim at (866) 481-1479 (select option 4).
The California Medical Association (CMA) has received a number of calls from physicians and their staff regarding the new Blue Shield contracts. As previously reported, Blue Shield is recontracting with physicians across the state. The new agreements were rolled out in phases across a majority of California’s counties, with doctors in Orange County receiving notice as recently as August 23.
Below are answers to the most common questions:
Why is Blue Shield asking me to sign a new agreement?
According to Blue Shield, the reason for the recontracting initiative is twofold: 1) Blue Shield has not done a large scale recontracting with physicians in over a decade, so the new contracts will ensure consistency and compliance with new laws and regulations; and 2) Blue Shield is offering various tiered networks based on price point in anticipation of possible participation in California’s Health Benefit Exchange and other new delivery models.
The new contract includes three new product types (Networks A, B and C). What types of products are these?
Exhibit B in the Blue Shield contract identifies these networks as Commercial PPO/EPO (Blue Shield Networks A, B and C), respectively reimbursing at staggered percentages of the rates set forth in the Blue Shield Provider Allowances. Blue Shield has advised CMA that these three tiered networks are being offered in anticipation of possible participation in the exchange.
CMA has been actively working with exchange stakeholders to address significant concerns regarding the exchange grace period, monitoring of network adequacy and clinician-level performance measurement in qualified health plans offered in the exchange. More information regarding contracting with exchange plans can be found in the “Reform Essentials” section of the CMA’s website, www.cmanet.org/cma-reform-essentials.
Can I designate which products I am willing to participate in?
Yes. Exhibit A of the new Blue Shield contract allows physicians to designate which products they are willing to participate in by product type. Additionally, a section of Blue Shield’s frequently asked questions (FAQ) encourages physicians to read Exhibit A carefully to ensure you clearly understand your participation choices.
Is there a fee schedule change associated with this new contract?
While Blue Shield did update its fee schedule statewide on July 1, there is no fee schedule change associated with this recontracting initiative, with the exception of the Direct Contract HMO Medicare product, which will be reimbursed at 95 percent of the Medicare allowed amount.
What happens if I do not sign and return the agreement by the date requested?
Blue Shield has assured CMA that if a physician chooses not to sign the new agreement, his or her participation status with Blue Shield will not be affected. However, you may receive a call from a Blue Shield representative if they do not receive the signed agreement by the specified date inquiring about the status.
Physicians are encouraged to carefully review and understand the vast range of legal and practical implications associated with the execution of any new contract and new product types.
To assist physicians, CMA recently published an updated analysis of the new Blue Shield contract, which is available to members in CMA's online resource library at www.cmanet.org/resource-library.
The Department of Health Care Services (DHCS) will soon be accepting applications from health plans interested in participating in the rural expansion of the Medi-Cal managed care program. The State Legislature authorized, as part of this year's budget, the expansion of Medi-Cal managed care into 25 rural fee-for-service counties. This expansion is part of the governor’s plan to reduce costs in the Medi-Cal program.
The California Medical Association (CMA) has learned that physicians in the expansion counties have started to receive requests from a health plans, asking them to sign "letters of intent" (LOIs) to participate in their Medi-Cal Managed Care products. The non-binding LOIs will allow the plans to determine how many physicians are willing to consider participation in the expansion.
Under the expansion program, eligible Medi-Cal enrollees will be required to enroll in a Medi-Cal managed care program in order to receive services, effective July 1, 2013.
In the notices to physicians, the health plans typically announce their intent to apply with DHCS to provide services to Medi-Cal beneficiaries as part of the rural expansion project and asks physicians to sign non-binding LOIs to participate in their potential network.
While each LOI will differ, some common provisions include language stating the agreement is non-binding, authorizing the payor to display the physician's name and address in a provider directory and stating that the parties agree to negotiate in good faith to execute a final agreement. The notices do not, typically, disclose reimbursement rates or enrollee volume a physician could expect to receive by participating in the network.
Physicians are reminded that participation in these networks is voluntary. Practices that choose to sign the LOIs are encouraged to retain a copy of the agreements for their records.
CMA encourages physicians to carefully review all proposed agreements, including LOIs, before signing.
More information on the Medi-Cal managed care rural expansion project, including the counties affected, visit the DHCS website.
The California Medical Association (CMA) has received a number of calls from physicians who have recently been terminated from Aetna’s provider network for referring Preferred Provider Organization (PPO) patients to out-of-network facilities.
CMA has prepared a guide to answer questions, provide options and resources available to physicians who have received a termination notice. The toolkit is available free to members in CMA's online resource library.
Affected physicians are also encouraged to call CMA's member help center for assistance.
Contact: CMA member help center (800) 786-4262 or memberservice@cmanet.org.
The California Medical Association (CMA) and the Department of Health Care Services (DHCS) are joining forces to educate physicians about a new program for dual eligibles called Community-Based Adult Services (CBAS).
Effective April 1, 2012, the CBAS program was established under California’s "Bridge to Reform" 1115 Medicaid waiver. CBAS is an outpatient, facility-based program that delivers skilled nursing care, skilled social services, skilled therapies, personal care, meals, transportation and caregiver training and support. The state established CBAS as part of an agreement to settle a lawsuit brought by Adult Day Health Care (ADHC) providers to prevent elimination of ADHC as a Medi-Cal benefit.
To help physicians understand the CBAS transition, CMA and DHCS will offer webinar-based training programs in the near future.
In the meantime, physicians should be aware of these important facts:
The CBAS transition is separate from the DHCS’ proposal to enroll dual eligibles into managed care, known as the "Coordinated Care Initiative." Under the Coordinated Care Initiative, starting in 2013, DHCS will pilot a duals demonstration program with the Centers for Medicare & Medicaid Services in eight counties – Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo and Santa Clara. The Coordinated Care Initiative is still pending federal approval. For more information about this initiative, visit cal.md/duals.
Physicians can still care for dually eligible patients even after the patient enrolls in a Medi-Cal managed care plan for their CBAS benefit.
Patients do not need to change Medicare physicians as a result of enrolling in Medi-Cal managed care to continue to get CBAS.
Physicians are not required to contract with a Medi-Cal managed care plan to ensure that patients continue to receive CBAS.
The majority of CBAS beneficiaries are dually eligible for Medi-Cal and Medicare. Under the terms of the settlement, most beneficiaries will have to enroll into a Medi-Cal managed care plan to get the CBAS benefit.
DHCS has worked to educate beneficiaries about how to enroll in a Medi-Cal managed care plan to keep their CBAS benefit. Despite these efforts, a large number of beneficiaries have opted to remain in Medi-Cal fee-for-service, which means they will no longer be eligible for CBAS benefits.
CMA recently hosted a webinar with DHCS on this issue. The webinar is now available for on-demand playback in the CMA resource library. The webinar will also be repeated live on November 28, 2012. To register for the next live webinar, which is free to all attendees, click here.
An odd grouping of health care interests will be represented on the keynote panel at this year’s Northern California Healthcare Conference’s, as Francisco Silva, general counsel for the California Medical Association (CMA) and vice president of CMA’s Center for Economic Services, joins a pool of speakers to discuss the future of independent medical practices.
Along with Silva, the panel, titled “Axis of Evil: Keep Your Friends Close and Your Enemies Closer: The Future of Independent Practice,” will feature Darryl Cardoza, CEO of Hill Physicians, C. Duane Dauner, president and CEO of the California Hospital Association, Cindy Farrington, senior vice president of Cooperative of American Physicians and Steven J. Snell, president of Health Net of California.
As a result of the changing landscape of health care in California, and the nation as a whole, these individuals and the entities they represent will be instrumental in how the independent medical practice continues into a post-health reform world.
The panel will be moderated by Cynthia Craft, the senior public health writer at the Sacramento Bee.
The 2012 Northern California Healthcare Conference is being organized by several chapters of the California Medical Group Management Association and will be held from 7:30 a.m. to 6 p.m. on Friday Oct. 5 at Thunder Valley Casino Resort.
For more information, or to register, visit www.camgma.com.
Yes, if the claim involves a fully insured HMO or PPO claim, there are two specific laws that may be helpful. First, check to see that the claims filing deadline imposed by the payor is consistent with the law. Payors can’t impose a deadline for receipt of a claim that is less than 90 days for contracted physicians and 180 days for non-contracted physicians (28 C.C.R. §1300.71(b) & Insurance Code 10133.66(a)). Providers are free to contract for claims filing deadlines outside of the 90 day minimum.
Additionally, if the payor is not the primary payor under coordination of benefits, payors can’t impose a deadline for submitting supplemental or coordination of benefits claims to any secondary payor that is less than 90 days from the date of payment or date of contest, denial or notice from the primary payor (28 C.C.R. §1300.71(b) & Insurance Code §10133.66(a)).
If your claim was denied for timely filing, the regulations also require the payor to allow for a “good cause” exception. Thus, physicians may be granted exceptions to the claim filing deadline if they can demonstrate a "good cause" for the delay. Upon the physician’s submission of a written provider dispute that demonstrates a good cause for the delay, the payor must accept and adjudicate the claim in accordance with state payment laws. (28 C.C.R. §1300.71(b)(4) & Insurance Code §10133.66.)
While the regulations fail to define "good cause," the DMHC has stated that they “…shall be the determiner of 'good cause' within the meaning of these regulations.”
Physicians should review their managed care contracts to ensure that, if they contain contractually agreed to deadlines that are less than those set forth above, that they are complying with those deadlines. In addition, even where a coordination of benefits (COB) provision is at issue, payors cannot impose shorter deadlines than the law allows. Any violations should be reported to the California Medical Association (CMA) and the regulator.
On the government side, Medicare requires claims be submitted within 365 days of the date of service and Medi-Cal requires claims be submitted within six months following the month in which the services were rendered. Medi-Cal claims submitted in months seven to nine are subject to a 25 percent payment reduction and those submitted in months 10 to 12 are subject to a 50 percent reduction.
More information on timeframes for claim submission, including a sample letter to appeal timely filing denials, can be found in CMA’s resource, “Know Your Rights: Timely Filing Limitations,” available on our website at www.cmanet.org/ces.
In a letter to Aetna, the California Medical Association (CMA) and 22 other state and specialty organizations, urged Aetna to discontinue implementation of additional accreditation requirements on physicians performing in-office pathology testing.
As CMA first reported in May 2012, Aetna notified all practices performing in-office pathology testing that they would be required to become both Clinical Laboratory Improvement Amendments (CLIA) certified and College of American Pathologists (CAP) accredited.Aetna later revised this requirement in the wake of concerns raised by CMA and the American Academy of Dermatologists over the dual certification requirement and the impact on physician practices.
As a result, in June, Aetna announced it was rescinding the requirement for dermatology and dermatopathology providers. Aetna also extended the implementation date of this policy for other specialties from August 1, 2012, to January 1, 2013. Additionally, Aetna announced an expanded list of acceptable accrediting organizations beyond CAP.
CMA has continued to voice concerns with the implementation of Aetna’s policy and the need for dual certification. As CMA originally pointed out, nearly all in-office surgical pathology labs are accredited by CLIA as the Centers for Medicare and Medicaid Services (CMS) requires. While CMS may recognize endorsement from other accreditation organizations, it does not require both a CLIA certification and a specialty society accreditation to perform in-office pathology testing services. Additionally, the process of obtaining and maintaining a secondary accreditation can be both costly and administratively burdensome for physicians and their practices.
CMA will continue its efforts with Aetna to lessen the impact of this undue and burdensome requirement.
The staff at the California Medical Association’s (CMA) Center for Economic Services (CES) has helped thousands of physicians looking for answers to reimbursement and payor-related questions over the years, but sometimes issues fall out of the scope of CES’ expertise.
Fortunately, the staff at CMA’s Center for Legal Affairs is always ready to assist in such situations.
One of these dedicated legal advocates is Melanie Neumeyer, who joined the CMA team back in August and has been making a difference for member-physicians ever since.
A recent graduate of the University of California, Davis’ School of Law, Neumeyer developed an interest in the legal aspects of health care early in her education, and says her current position allows her to use those interests to directly benefit CMA members.
“I like interacting with our members because it brings purpose to my day,” she said. “I like knowing that someone benefits by me going to work every day. The best way to know that is to talk to people directly and hear how grateful they are for the services CMA provides.”
As part of CMA’s legal help line, Neumeyer helps provide members with information and resources about laws and regulations that impact the practice of medicine.
While CMA staff cannot provide physicians with individual legal advice, this team of health law information specialists, with the support of CMA legal counsel, helps members find legal information and resources on a multitude of health-law related issues, ranging from OSHA requirements to the retention of medical records.
As with CMA’s reimbursement assistance line, the legal help line is free to members and a resource that Neumeyer says all CMA members should be aware of.
“Members should never hesitate to call CMA,” she said. “Our attorneys are experts in their field and work very hard to give accurate and timely information to all of our members.”
Contact: CMA’s reimbursement helpline (888) 786-4262 or legalinfo@cmanet.org.
Under both the Center for Medicare & Medicaid Services (CMS) and CPT® guidelines, an Evaluation and Management (E/M) service may be separately billed with a minor procedure as long as the E/M service was clearly documented and substantiated and modifier 25—Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service—is properly appended to the appropriate E/M service code.
CMS transmittal R954CP (Medlearn Matters number: MM5025, change request (CR) 5025) instructs coders to apply modifier 25 for “a significant, separately identifiable E/M service that is above and beyond the usual pre- and post-operative work for the service,” and to “appropriately and sufficiently” document medical necessity for both the E/M service and the other service or procedure.
Both the procedure and the separate, same-day E/M service must be linked to an approved diagnosis, substantiated in the medical record. The diagnoses supporting each service may be the same or different. Per transmittal R954CP, “The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date” [emphasis added].
The American Medical Association (AMA) guidelines, as outlined in the CPT® codebook and CPT® Assistant, also clearly and consistently support coding for a minor procedure and a separate, significant same-day E/M with modifier 25. Below are three such examples from CPT® Assistant, involving varying specialties and spanning nearly 20 years.
Example 1 (Winter 1993, CPT® Assistant):
…a physician examines a patient with a fever, headache, vomiting and stiff neck. A spinal tap is performed as well as the services described in code 99214. The -25 modifier is appended to code 99214 to indicate that both a significant E/M service and a procedure were performed on a given day.
Example 2 (May 2003, CPT® Assistant):
A physician examines a new patient exhibiting symptoms of an upper-respiratory infection that has progressed to unilateral purulent nasal discharge and discomfort in the right maxillary teeth. The physician performs and documents a detailed history and detailed examination. The physician determines that the medical decision making is of low complexity and also documents this in the patient’s medical record. This new patient encounter is reported with E/M service code 99203 Office or other outpatient visit.
During the examination, the patient communicates to the physician that the hearing in his left ear is not as distinct as his right ear. Upon examination of the left ear, the physician notes a large amount of impacted cerumen. The physician proceeds to suction the impacted cerumen in the patient’s left ear.
To report this patient encounter, the physician appends Modifier ‘-25’ to code 99203, and separately reports code 69210, Removal impacted cerumen (separate procedure), one or both ears to indicate that both a significant E/M service and a procedure were performed on a given day.
Example 3 (May 2011, CPT® Assistant):
A 4-year-old slips on the edge of a pool, strikes the mandible and experienced a 3.5-cm serrated and curvilinear, full-thickness laceration of the chin. The child’s pediatrician elects to widely excise the serrated skin margins and undermine the dermis from the subcutaneous tissue to reduce the tension on the suture line. The wound is then approximated in layers with absorbable interrupted sutures and a running subcuticular closure.
This procedure would be reported with code 13132, Repair complex, forehead, cheeks, chin, mouth neck, axillae, genitalia, hands and/or feet; 2.6 to 7.5 cm. Any significant, separately identifiable evaluation and management (E/M) service performed in addition to the wound repair would be reported separately using modifier 25.
All services and procedures include an “inherent” E/M component. A brief history and physical prior to a same-day scheduled outpatient procedure are included components of the procedure itself. Even if the physician provides an assessment and plan, you probably should not report a separate E/M service unless the patient has a new, unrelated complaint or has experienced a worsening of symptoms that prompts a new history, exam and medical decision-making process that might include additional testing or therapy.
The question persists: How do you decide if an E/M service is truly “significant” and “separately identifiable” (and separately reportable with modifier 25)? Ask yourself, “Can I pick out from the documentation a clear history, exam and medical decision-making process apart from any other procedures the physician performs on the same day?” If so, you’ve probably got a billable service with modifier 25.
For more coding tips, visit CMA’s resource library and search “Coding Corner.”
As previously reported, Anthem Blue Cross notified physicians in early August of upcoming changes to the insurer’s reimbursement policies and claims editing software, ClaimsXten. Most changes will go into effect on December 8, 2012, with a few exceptions that go live on January 1, 2013. With 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 all new, revised and existing reimbursement policies and claims editing rules as well as copies of Anthem’s reimbursement policies.
Updates include: assistant surgeon and co-surgeon codes eligible for payment, frequency edits on certain codes, multiple surgery reductions for certain endoscopic procedures performed on the same day, application of multiple procedure reduction for the technical component of certain diagnostic imaging procedures performed on same day, restrictions on payment for prolonged services codes 99354 and 99355 and denial of certain screening services (e.g.,Q0091, G0101, G0102) when billed with preventive or problem focused evaluation and management codes.
Physicians are encouraged to review the claims editing changes as well as the corresponding detailed payment policies to understand how the changes will affect their individual practices.
Physicians can also access the information in the mailer via the Blue Cross website, www.anthem.com. (Log into the provider portal and select “Reimbursement Policies and McKesson ClaimsXten Rules” under the “What’s New” section.)
Questions about any of the claims editing rules or payment policies can be directed to Blue Cross Provider Care Department at (800) 677-6669.
Effective October 1, 2012, there will be what is probably the most significant change to date in the National Correct Coding Initiative (NCCI) database. There will be 233,241 new edit pairs added, with over 97 percent of these being surgical procedures (codes 10000 through 69999). Almost all of these new edit pairs fall within the policy statement of “Misuse of Column 2 code with Column 1 code.” There will be 83 edit pairs that have been terminated for this release.
There were also 474 edit pairs where the modifier indicator was changed from ‘1’ (you may be able to bypass the policy using a modifier) to ‘0’ (modifiers are not permitted under any circumstance). Two edit pairs were changed from an indicator of ‘0’ to an indicator of ‘1.’
Physicians who perform procedures described within the surgical section of CPT may want to review the codes they commonly bill to determine if there are any changes affecting their practices. These changes affect Medicare and other private payors who use the NCCI as their base for bundling policies.
The Frank Cohen Group has prepared a detailed workbook that contains the new pairs, terminated pairs and modifier changes, so you can check to see which, if any, of your codes were impacted. To get the worksheet, go to www.FrankCohenGroup.com, click on the Library tab and then the Research and Studies link. It will also be under the “What’s New” tab on the home page.
The Middle Class Tax Relief and Job Creation Act of 2012 (H.R.3630) was signed into law on February 22, 2012, extending the Medicare Part B Outpatient Therapy Cap Exceptions Process through December 31, 2012. This exceptions process allows providers to receive payment from Medicare for medically-necessary therapy services above the therapy cap amount.
Beginning on October 1, 2012, some therapy providers will be required to submit requests for exceptions (pre-approval for up to 20 therapy treatment days for beneficiaries at or above the $3,700 threshold). This requirement will be phased in and therapy providers will be assigned to three groups or phases. The requirement to submit an exception request will be imposed on them on the dates listed below, depending on which of the three groups or phases to which they are assigned.
Phase I: October 1 to December 31, 2012
Phase II: November 1 to December 31, 2012
Phase III: December 1 to December 31, 2012
If you are a provider of physical therapy, speech-language pathology services or occupational therapy services, you may receive a letter titled "Notification of Request for Exception Requirements for Therapy," indicating your assigned phase. You can find your assigned phase here. If you do not find your NPI number on the list, then you are in Phase III. Additional information on how to obtain prior approval for therapy can be located on the Palmetto GBA website under the “Therapy” specialty tab of the Jurisdiction1 Part B page.
“Recently we had an insurance audit that would have resulted in a large refund from our doctors. Tackling this request, I was advised to call the CMA for assistance and I am so glad I did. The CMA representative was so responsive and professional. They were able to give me the guidance I needed, which resulted in the insurance company dropping their refund request. I do not feel this would have been possible without the valuable advice I received from the CMA. I know I will seek out their advice in the future.”
Mary Whitten, ROCC
Charlotte Kim, M.D., Oncure Medical Corporation
CMA Member since 1999
AETNA: Aetna recently notified physicians through their Aetna OfficeLink Update of changes to the Aetna National Precertification List (NPL) that become effective January 1, 2013. Aetna has also indicated that effective September 1, 2012, notification is no longer required for several outpatient scopes, including bronchoscopy, cystoscopy, hysteroscopy, knee arthroscopy, laparoscopic cholecystectomy and shoulder arthroscopy. Notification for colonoscopy and upper GI endoscopy will remain a requirement. For more information on the specific changes visit the Aetna website at www.aetna.com.
ANTHEM BLUE CROSS: On July 27, Anthem notified physicians by mail and also announced in the September 2012 Network Update changes to their sleep testing and therapy policies. As part of these changes, physicians will be required to obtain a prior auth for sleep testing and therapy services through AIM (see notice for exceptions to the prior auth requirement). They will also begin allowing home sleep tests. Beginning October 15, physicians can contact AIM to obtain a prior authorization for these services.
Blue Cross also announced updates to their medical policies on diagnostic for certain imaging procedures including CT, MRI, CTA, myocardial perfusion and stress echocardiography. See their September 2012 Network Update for more information.
UNITED: United Healthcare has sent their Annual Physician and Practice Manager Satisfaction Survey to randomly selected practices. The survey provides physicians and practice managers the opportunity to provide feedback on United’s services. If you did not receive a survey and would like to provide feedback, you can complete the survey at www.msisurvey.com/H12113.
United Healthcare has announced several updates to their medical policy, effective October 1, 2012 including the change for Cardiology services from prior notification to prior authorization for Medicare Advantage benefit plans. Additional information and updates can be obtained by visiting the United website, www.UnitedHealthcareOnline.com, and selecting the Tools & Resources tab.
The California Medical Association (CMA) offers our members free programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon. Most events are PMI CEU Credit Approved.
Upcoming CMA webinars
Most webinars are held over the lunch hour, from 12:15 to 1:15 p.m. and are free for CMA members and their staff. See the event calendar for additional details.
10/10: Impact of ICD-10
ICD-10 will bring about some massive changes in healthcare. No matter what the implementation date, you need to understand how you will be impacted and what you should be doing now to prepare.
10/17: Establishing Expectations for High Performance from Medical Staff
Superstar staff members are made, not born. Staff usually rise to the owner or manager’s level of expectations. This webinar will teach physicians/managers how to set high expectations for performance, create monitoring tools to evaluate and reward staff who achieve stellar performance.
10/18: Essentials for ICD-10-CM: Part 1
7:45 to 8:45 a.m. or 12:15 to 1:15 p.m.
Available in either classroom or online webinar, this 3-part series gives your staff a high-level overview and fundamental knowledge of ICD-10. You’ll learn documentation challenges, the differences with ICD-9, and how ICD-10 will affect each business area of your practice. This series continued on October 25 and November 1.
10/24: A Strategic Approach to Managing Your Medical School Debt
Presented by GL Advisor, this webinar will help educate you on how to better manage your medical school debt. This webinar describes how utilizing federal student debt relief programs, such as Income-Based Repayment and Public Service Loan Forgiveness, in addition to other structured repayment strategies, can help lower the cost of debt and maximize savings.
For more information or to register for CMA webinars, view the CMA event calendar.
Contact: CMA’s member help center, (800) 786-4262 or memberservice@cmanet.org.
MEDICARE/PALMETTO GBA: www.palmettogba.com/j1b. Click on "Publications" in the left sidebar, then on "Medicare Advisory."