San Francisco Medical Society Blog

UMVS Indemnification Clause May Limit Coverage for Malpractice Claims

Thu, 16 May 2013 15:58:28 GMT

SFMS/CMA has recently become aware that a broad "indemnification" clause in the UnitedHealth Military & Veterans Services (UMVS) TRICARE provider contracts is causing some professional liability carriers to exclude coverage for services provided to TRICARE beneficiaries.

Although California's Knox Keene Act prohibits indemnification clauses in physician contracts, the contract in question is governed by federal law. Indemnification clauses are not uncommon, and usually are used to restrict liability in the case of willful misconduct. The clause in the UMVS contract, however, is so broad that at least two professional liability carriers have indicated that they would not defend or indemnify the physicians in the event of a claim brought by a TRICARE beneficiary.

SFMS/CMA has escalated this issue to high level contacts at UMVS. We will provide additional information as it becomes available. In the meantime, physicians are urged to reach out to their liability carriers to determine if they are covered when treating TRICARE patients.

SFMS members with reimbursement questions can contact our Member Helpline for one-on-one assistance at (800) 786-4262.

SFDPH Health Advisory: Human Infections with Avian Influenza A: H7N9

Tue, 07 May 2013 11:31:06 GMT

May 1, 2013 (Revised from April 12, 2013)

The U.S. Centers for Disease Control & Prevention (CDC) has updated its interim guidance:

Antiviral Treatment: Due to the potential severity of illness associated with Avian Influenza A:H7N9 virus infection, CDC now recommends that all confirmed, probable, and suspect cases of Avian Influenza A:H7N9, including outpatients with uncomplicated illness, be treated with neuraminidase inhibitors as early as possible, without waiting for laboratory confirmation of influenza before initiating treatment.

Infection Control Guidance has been updated; Droplet precautions are no longer recommended but Standard, Contact and Airborne precautions should be implemented by health care personnel; suggestions are provided for clinics unable to fully implement Airborne Precautions.

Case Definitions: A definition for Suspect cases (Cases Under investigation) has been added, defining Suspect as patients with influenza-like illness (ILI1) with:

Recent contact (within ≤ 10 days of illness onset) with a confirmed or probable case of infection with Avian Influenza A:H7N9 virus; or
Recent travel (within ≤ 10 days of illness onset) to a country where human cases of Avian Influenza A:H7N9 virus have been recently detected or where Avian Influenza A:H7N9 viruses are known to be circulating in animals. (As of 4/29/13, those countries are China and Taiwan).

Actions Requested of Clinicians

IMPLEMENT Standard, Contact and Airborne Precautions2, including eye protection and respirators, for health care personnel caring for patients meeting criteria for a Suspect case of Avian influenza A:H7N9. Place a surgical mask on the patient to reduce spread of respiratory secretions and have the patient avoid public settings (e.g., public transportation). Aerosol-generating procedures should be performed only if they are medically necessary and cannot be postponed.
REPORT suspected Avian influenza A:H7N9 in patients who meet the criteria described in the case definition for case under investigation (CUI). Call the SFDPH Communicable Disease Control Unit at (415) 554-2830; after hours, weekends and holidays press “1” and “1” again to page the on call physician.
COLLECT specimens for testing and, after obtaining approval from SFDPH Communicable Disease Control, send specimens to SFDPH Public Health Laboratory per instructions below.
TREAT empirically with neuraminidase influenza antiviral medications (oral oseltamivir or inhaled zanamivir) as soon as possible, without waiting for laboratory confirmation in all patients who meet the case definition for case under investigation, including outpatients with uncomplicated illness.
CONSULT an infectious disease specialist and/or the CDC webpage3 for updated information

Click here to view the SFDPH health advisory on Avian Influenza A: H7N9.

For more information about health alerts, advisories, and updates from the San Francisco Department of Public Health, please visit http://www.sfcdcp.org/healthalerts.html.

“Pause Before Posting”: New Ethical Guidelines for Physicians and Social Media Usage

Fri, 12 Apr 2013 14:52:04 GMT

Physicians should exercise caution—and “pause before posting”—when interacting in online settings in order to preserve professionalism and maintain appropriate patient-physician relationships, according to a policy paper released today by the American College of Physicians and the Federation of State Medical Boards.

“Online Medical Professionalism: Patient and Public Relationships” addresses the use of online and social media and electronic communication between physicians and patients. The two organizations looked at opportunities and challenges created by new technologies and online forums, and provided recommendations and strategies for physician behavior in these areas.

Digital communications and social media use continue to increase in popularity among the public and medical profession. The ACP policy paper discusses best practices to inform standards for the professional conduct of physicians online and includes a chart of online activities, potential benefits and dangers, and recommended safeguards for physician behavior.

Notable recommendations from ACP and FSMB include:

Physicians should keep their professional and personal personas separate. Physicians should not “friend” or contact patients through personal social media.
Physicians should not use text messaging for medical interactions even with an established patient except with extreme caution and consent by the patient.
E-mail or other electronic communications should only be used by physicians within an established patient-physician relationship and with patient consent.
Establishing a professional profile so that it “appears” first during a search, instead of a physician ranking site, can provide some measure of control that the information read by patients prior to the initial encounter or thereafter is accurate.

The paper will be published in the April 16 issue of Annals of Internal Medicine, and is authored by ACP’s Ethics, Professionalism and Human Rights Committee; ACP’s Council of Associates; and FSMB’s Committee on Ethics and Professionalism.

Click here to view the complete policy paper.

Click here for the ACP press release.

FAQs: Affordable Care Act Primary Care Rate Increase & Medi-Cal State Plan Amendment

Fri, 12 Apr 2013 12:41:22 GMT

Under the provisions of the federal Affordable Care Act (ACA), Medi-Cal is required to pay primary care physicians at Medicare rates for primary care services for two years. The increase is fully funded by the federal government. The requirement began January 1, 2013 and ends December 31, 2014.

The California Department of Health Care Services (DHCS) submitted their state plan amendment (SPA) to implement the rate increase on March 29, 2013. Approval of the SPA is required by the Centers for Medicare and Medicaid Services (CMS) before the state can implement the rate adjustment. It is unclear when the rate adjustment will be approved by CMS and implemented by DHCS. In previous communications, DHCS has indicated that they expect implementation will begin in July 2013. However, the rate adjustment will be retroactive to the beginning of the year.

Below are answers to frequently asked questions about implementation of the rate adjustment as outlined in the SPA. Please note these provisions are subject to change pending approval by the CMS.

Why is the SPA just being filed now?

Federal guidance on the implementation of the rate increase was delayed until November 2012. The DHCS claims that the federal delay and the complications involved with applying the rate increase to managed care delayed the submission of the SPA.

Who qualifies as a “primary care physician”?

Any physician who is board-certified in internal medicine, family medicine, or pediatrics by the American Board of Physician Specialties, the American Board of Medical Specialties, or the American Osteopathic Association. This includes recognized physician subspecialties of the above board certified specialties.

Or, any physician who practices (but is not board certified) in a specialty or sub-specialty of internal medicine, family medicine, or pediatrics who also bills at least 60% of services rendered for qualifying codes. DHCS has indicated that billing 60% of services for qualifying codes alone does not qualify a physician unless they also can legitimately attest to practicing in internal medicine, family medicine or pediatric medicine or a subspecialty of internal medicine family medicine or pediatric medicine recognized by the ABMS, ABPS or AOA.

Click here to view the list of qualifying primary care providers (PCP).

How will physicians prove that they qualify?

Generally, physicians will self-attest that they qualify for the increased rates. DHCS is developing an online registry that physicians will use to register. However, managed care plans are allowed to choose to either use the DHCS attestation tool or develop their own.

What counts as a primary care service?

The rate increase applies to:

Evaluation and management codes 99201-99499
Vaccine administration codes 90460, 90461, and 90471-90474
Preventive care codes 99381-99387 and 99391-99397
Counseling risk/behavior intervention codes 99401, 99404, 99408-409, 99411, 99412, 99420 and 99429

The rate increase also applies to state-specific “Z” codes—Z0100, Z0102, Z0104, Z0106 and Z0108. These codes are relevant to some state-only programs, such as Family PACT, as well as many services provided in neonatal and prenatal intensive care units (NICU and PICU).

What Medicare rates will Medi-Cal use? Will they apply the GPCIs?

Per the SPA, rates will be based on the 2009 Medicare Fee Schedule. Geographic Payment Center Indices (GPCIs) will apply. SFMS/CMA urged the DHCS to adopt this approach based on our analysis that this approach would benefit California physicians.

Are clinics or physician employers eligible for the Medi-Cal reimbursement adjustment?

No, only the physician who is personally providing the service is eligible for the increase.

Does the increase apply to managed care?

Yes. Plans will be receiving increased payments, through the State of California, to pay providers at Medicare rates. The increase is fully funded by the federal government for 2 years beginning January 1, 2013 and ending December 31, 2014.

How will the state guarantee that the money actually makes it to the physician?

Plans will be contractually obligated to prove that they are paying primary care physicians at least the Medicare rates. The payments made to plans to cover the increased cost of higher rates will be separate from their general capitation payments, allowing for separate accounting. The SPA included plan reporting requirements to ensure the rate adjustment funding is going to the service providing physician.

Questions & Assistance

SFMS/CMA members with questions about Medi-Cal reimbursements can receive complimentary one-on-one assistance by contacting our Member Helpline at (800) 786-4262.

Common Disputes in Employed Physician Contracts

Wed, 10 Apr 2013 14:37:05 GMT

Many times, contract disputes arise because of misunderstandings about what hospitals and health systems expect of physicians. A good contract will define a doctor's role and how he or she is to be paid. But some contracts are not well-written, leading to misunderstandings and miscommunications, which end up pitting physicians against their employers.

Here are some common contract disputes:

Productivity compensation. It used to be that physicians were paid base salaries, but now it's more commonly base plus bonus. Many disputes arise due to interpretations of relative value unit formulas.

Termination agreement. Some physicians misinterpret when they can terminate their contracts. Contracts may appear to say that doctors must give hospitals notice within a certain time frame. But depending on the way it's written, a contract might mean the doctor has to give notice within a certain time frame before the anniversary of the start of the employment contract.

Geographic coverage. Some contracts define the geographic areas physicians are required to work in, which are spelled out as specified distances from hospitals. But the contracts might not define the word “hospital.” It may mean any clinic associated with a hospital, so some doctors must travel greater distances than expected to get to their practices.

Noncompete clauses. This part of a contract allows a physician to practice medicine outside a certain distance from a hospital after he or she leaves. Some contracts don't allow doctors to practice medicine within a specified distance of any medical practice affiliated with a hospital. That may mean the geographic distance is far larger than physicians assumed when they signed their contracts.

SFMS Member Resources

Assessing and reviewing your contracts is essential to getting the most out of any contract proposal, whether it involves employment agreements, managed care contracts, shareholder agreements or hospital-based contracts. Because the "devil is in the details," ambiguously worded contracts may not contain the provisions meant to protect you and your medical practice from detrimental deals.

SFMS members can access a number of resources and services to assist in simplifying the at-times-daunting contract review. One such resource is CMA's contract analysis service through which SFMS members can receive written reviews of specific physician contracts. Members receive a 20% discount on attorney's fees of the law firm that has contracted to do these reviews. The analysis fee depends upon the type of contract to be reviewed. Included in the price are an initial appointment (either by phone or in person) prior to the analysis and an additional appointment after the physician has received the analysis, if the physician so desires.

Click here for additional information and rates.

What Providers Need to Know about EHR Audits

Wed, 10 Apr 2013 13:59:47 GMT

All eligible professionals (EPs), eligible hospitals, and critical access hospitals (CAHs) attesting to receive an incentive payment for either the Medicare or Medicaid Electronic Health Record (EHR) Incentive Program may be subject to an audit.

Pre- and Post-Payment Audits

CMS and its contractor, Figliozzi and Company, perform audits on Medicare and dually-eligible (Medicare and Medicaid) providers who are participating in the EHR Incentive Programs. States perform audits on Medicaid providers participating in the Medicaid EHR Incentive Program.

In addition to the post-payment audits that have been conducted since 2012, CMS began pre-payment audits this year, starting with attestations submitted during and after January 2013.

New Resources to Prepare for Audits

For those providers selected for pre-payment or post-payment audits, CMS and its contractor will request supporting documentation to validate submitted attestation data. To help providers prepare for a potential audit, CMS created the new Supporting Documentation for Audits Fact Sheet. The fact sheet and a sample audit request letter for both EPs and eligible hospitals are also available on the Educational Resources page of the EHR Incentive Programs website.

Additional Information About the EHR Incentive Programs?

Make sure to visit the EHR Incentive Programs website for the latest news and updates on the EHR Incentive Programs.

Click here for additional resources from CMS regarding audit information and guidance.

Questions or request for more information? Please contact the CMS San Francisco Regional Office at (415) 744-3658 or rosfofm@cms.hhs.gov.

Medicare Ordering/Referring Claims Denials to Take Effect May 1

Wed, 27 Mar 2013 15:33:01 GMT

Medicare will begin denying claims on May 1, 2013, if the ordering/referring provider listed on the claim is not in the Provider Enrollment, Chain and Ownership System (PECOS), the database Medicare uses to track physicians and other providers.

If you bill Medicare, you are encouraged to note any Medicare EOBs with the remittance code N264 and/or N265, which may indicate that the ordering/referring provider on the claim is not yet in PECOS. These providers must take action to enroll in PECOS or future claims that you submit with these providers listed for dates of service on or after May 1 will be rejected.

Physicians and other providers are not required to enroll with Medicare to provide services in order to be listed in PECOS. Physicians who wish to be listed in PECOS solely for ordering/referring purposes may submit an enrollment application online via the PECOS website or by completing a CMS-855o paper enrollment application.

Click here to access the PECOS system to determine if you or another physician is currently enrolled in PECOS.

Click here to download a paper CMS-855o application.

Click here for the MLN Matters article for details about the update on PECOS and ordering/referring.

Sequestration FAQ for California Physicians

Mon, 11 Mar 2013 12:33:22 GMT

The $85.4 billion 2013 sequester includes a 2% cut (or $10 billion) in Medicare provider payments. Below are answers to frequently asked questions about the sequestration cuts.

When do the cuts take effect?

All cuts were triggered on March 1, but most cuts will not happen until April 1. Physicians who see Medicare patients will see a 2% reduction in their payments beginning April 1.

What Medicare cuts can physicians expect?

Per CMS, the Medicare fee-for-service program (Part A and Part B) claims with dates-of-service or dates-of-discharge on or after April 1, 2013, will be reduced by 2%.

Claims for durable medical equipment (DME), prosthetics, orthotics, and supplies, including claims under the DME Competitive Bidding Program, will also be reduced by 2% for claims with dates-of-service on or after April 1, 2013.

The claims payment adjustment will be applied to all claims after determining coinsurance, any applicable deductible and any applicable Medicare secondary payment adjustments.

Though beneficiary payments for deductibles and coinsurance are not subject to the 2% payment reduction, Medicare’s payment to beneficiaries for unassigned claims is subject to the 2% reduction. CMS encourages Medicare physicians who bill claims on an unassigned basis to discuss with beneficiaries the impact of sequestration on Medicare’s reimbursement.

The sequestration cuts are 2% across the board for all Medicare fee-for-service claims. It also affects physicians contracting with Medicare Advantage plans. Medicare Advantage plan payments will also be cut by 2%.

Certain details of the Medicare sequester still have not been made public. For example, we do not yet know how the Medicare Advantage plans will pass down the payment cuts to contracting or employed physicians.

How do I bill Medicare after March 1, 2013?

Physicians should continue billing as usual until more guidance has been provided by the Centers for Medicare and Medicaid Services.

Will Medicare EHR incentive payments be cut?

While CMS has released no specific information on how it will handle the sequestration cuts, there is a possibility that providers may see a 2% cut to their EHR “meaningful use” incentive payments. This money had been set aside under the 2009 federal economic stimulus package for both Medicare and Medicaid, so it is unclear whether it will be impacted by the sequestration cuts. Medicaid is exempt from the sequester.

What programs are exempt from the sequestration?

Medicaid, Social Security and the Veteran’s Administration are exempt from the cuts.

How will the cuts impact health care in California?

The White House issued a report showing that California would be impacted by the following cuts: Medicare, public health, childhood vaccinations, mental health, AIDs and HIV treatment and prevention.

Vaccines for Children: Reduced funding for the federal Vaccines for Children program means that approximately 15,810 fewer children in California will qualify for free vaccines for diseases such as measles, mumps, rubella, tetanus, whooping cough, influenza and Hepatitis B.

Public Health: California will lose approximately $2.6 million in funds to respond to public health threats including infectious diseases, natural disasters and biological, chemical, nuclear, and radiological events. In addition, California will lose about $12.4 million in grants to help prevent and treat substance abuse, resulting in around 9,400 fewer admissions to substance abuse programs. California will also lose $2 million for AIDS treatment and HIV prevention.
Medicare: All Medicare physician services and Medicare Advantage plans will be cut by 2%. Graduate Medical Education and all other programs within Medicare will be negatively impacted as well.

Click here for the White House summary of the impact of the 2013 sequestration on California.

What can I do to help stop these cuts?

It is not too late for physicians to contact Congress to explain the impact that a 2% Medicare payment cut will have on physicians and their patients.

Given that most of the cuts won’t actually be implemented until April 1, it is possible that Congress will eventually come to an agreement and reverse some of the sequestration cuts.

Contact your U.S. representative and senators today; send them an email and call their offices through AMA’s grassroots hotline at (800) 833- 6354. Enter your zip code and you will be automatically connected to your representatives. Your patients can help, too, by contacting Congress through the AMA’s Patients’ Action Network hotline at (888) 434-6200.

Physician Group Coalition Expands List of Overused Tests, Treatments in Choosing Wisely Campaign

Thu, 21 Feb 2013 14:13:55 GMT

17 medical specialty societies have added their names and recommendations to a list of overused tests and procedures that should be avoided.

The updated list—which includes 90 new items—was released today that includes tests and procedures that participating societies consider possibly unnecessary or harmful.

The project, known as “Choose Wisely,” is being spearheaded by the American Board of Internal Medicine (ABIM) with the hope that the list will encourage patients and physicians to follow evidence-based guidelines in managing health problems, while avoiding procedures that could cause more harm than good.

While the campaign itself won’t measure any cost reductions achieved, there are billions in savings to be had by eliminating waste. The U.S. spends an estimated $2.5 trillion a year on health care, or more than $8,000 per person—far more than in other developed countries. Much of that money is wasted. The U.S. health care system squandered about $750 billion a year as of 2009, or more than a third of total health care expenditures, according to a report released last year by the Institute of Medicine. That included some $210 billion in excess costs due to unnecessary services.

The new recommendations include:

Waiting 6 weeks to do imaging for low back pain, unless red flags are present.
Avoiding elective, non-medically indicated inductions of labor between 39 weeks and 41 weeks.
Not requiring annual pap tests in women ages 30 to 65.
Steering clear of ordering antibiotics for adenoviral conjunctivitis.
Not ordering continuous telemetry monitoring outside of the ICU without using a protocol that governs continuation.

The full list of questionable tests and procedures is available at ChoosingWisely.org.

ABIM hopes to release a third list later this year that will include 13 more societies, including the American Academy of Dermatology and the American Academy of Orthopaedic Surgeons.

Click here to download the full list of Five Things Physicians and Patients Should Question (for physicians).

Click here to read about how the Choosing Wisely Campaign was launched from ABIM Board Chair, Catherine Lucey, MD.

Anthem Requires Contracted Providers to Notify Patients Before Making Out-of-Network Referrals

Fri, 25 Jan 2013 11:38:31 GMT

In late November, Anthem Blue Cross announced that it would soon begin requiring contracted physicians to notify patients in writing before making out of network referrals. Effective March 1, the payor’s new “Advance Notice for Use of a Non-Participating Provider Policy” (APN policy) requires this notice be given using the payor-provided APN form. The policy does not apply to emergencies.

While Blue Cross has included language in its contracts since 2008 requiring physicians to disclose to patients and document the same type of information included in the APN form, it was not often enforced.

According to Blue Cross, it frequently receives complaints from patients who were unaware that they were being referred to out-of-network providers. The payor says that its new policy is not intended to deter patients from using their out-of-network benefits. Rather, it is intended to help patients make informed decisions about their coverage and options.

Boston Declares Health Emergency Amid U.S. Flu Outbreak; Resources for Health Care Providers

Thu, 10 Jan 2013 11:40:55 GMT

The country is in the grip of three emerging flu or flulike epidemics: an early start to the annual flu season with an unusually aggressive virus, a surge in a new type of norovirus, and the worst whooping cough outbreak in 60 years. And these are all developing amid the normal winter highs for the many viruses that cause symptoms on the “colds and flu” spectrum.

Google’s national flu trend maps, which track flu-related searches, are almost solid red (for “intense activity”) and the Centers for Disease Control and Prevention’s weekly FluView maps, which track confirmed cases, are nearly solid brown (for “widespread activity”).

With flu cases in this city up tenfold from last year, the mayor of Boston declared a public health emergency on Wednesday as authorities around the United States scrambled to cope with a rising number of patients.

Health authorities say a virulent strain this year has caused the number of flu cases to surge earlier than usual. Hospitals around the country have scrambled to find additional space to treat the ill, and some have had to turn people away.

The U.S. Centers for Disease Control and Prevention (CDC) reported that the proportion of people visiting their doctors for flu-like illnesses has doubled in the past four weeks.

Encouraging vaccinations is one of the most effective steps in combating what looks to be a serious strain of the flu, said Dr. William Hanage, an associate professor of epidemiology at the Harvard School of Public Health.

The flu season typically picks up in December, builds to a peak in January or February and fades away by late March or early April.

Flu Information for Health Care Providers

San Francisco Department of Public Health Health Officer order regarding mandatory influenza vaccination or masking for health care professionals during flu season
Flu information from the SFDPH Communicable Disease Control and Prevention, including vaccination guide and health alerts
American Public Health Association's report on early start of flu season, December 4, 2012.
CDC Report of 2012-2013 Influenza Season Week 52 Ending December 29, 2012.

From CMS Region 9 (San Francisco Regional Office): Information Regarding the 2013 Medicare Physician Fee Schedule

Wed, 19 Dec 2012 14:20:03 GMT

The negative update of 27% under current law for the 2013 Medicare Physician Fee Schedule is scheduled to take effect on January 1, 2013.

Medicare Physician Fee Schedule claims for services rendered on or before December 31, 2012, are unaffected by the 2013 payment cut and will be processed and paid under normal procedures and time frames.

The Administration is disappointed that Congress has failed to pass a solution to eliminate the sustainable growth rate (SGR) formula-driven cuts, and has put payments for health care for Medicare beneficiaries at risk. We continue to urge Congress to take action to ensure these cuts do not take effect. Given the current progress with the legislation, CMS must take steps to implement the negative update.

Under current law, clean electronic claims are not paid sooner than 14 calendar days (29 days for paper claims) after the date of receipt. CMS will notify you on or before January 11, 2013, with more information about the status of Congressional action to avert the negative update and next steps.

SFMS/CMA and DHCS to Present Complimentary December Webinar About "Coordinated Care" Initiative

Mon, 10 Dec 2012 12:49:57 GMT

The California Department of Health Services (DHCS) and the SFMS/CMA are sponsoring a free webinar on the state’s new Coordinated Care Initiative (CCI) for dual eligibles—Californians eligible for both Medi-Cal and Medicare. The webinar takes place on December 19, 2012, from 12:15pm to 1:15 pm and is free for all physicians.

The Coordinated Care Initiative (CCI) was authorized by the Assembly in July 2012 in an effort to save money and better coordinate care for the state’s low-income seniors and persons with disabilities. The program begins with a three-year demonstration project that would see more than 75% of California’s dual eligible beneficiaries transition to managed care plans.

Although the project is still pending federal approval, DHCS plans to begin passively enrolling dual eligible patients residing in eight of California's largest counties beginning in 2013. Under the pilot program, patients will be enrolled in a managed care plan unless they actively opt out.

SFMS/CMA remains concerned over the breadth of this so-called pilot project and has urged CMS to require the state to scale it back. Any transition that involves 75% of all dual eligibles cannot be considered a pilot. In October, the CMA’s annual House of Delegates authored a resolution that calls on CMA to collect data from its membership regarding difficulties with the duals transition and, if difficulties are found to be widespread, report them to DHCS, the California Department of Managed Health Care and CMS.

Click here to register for the December 19 free webinar.

Obamacare—Past, Present, and Future, Part 4

Wed, 28 Nov 2012 14:47:43 GMT

By Andy Calman, MD, PhD

Note: This article was originally published in the October 2012 issue of San Francisco Medicine. Due to members' request for more information on health care reform and its impact on medicine, SFMS is publishing a four-part series in the SFMS blog section. Click here to read Part 3 of this 4-part series on Obamacare and its impact on U.S. physicians and patients.

How Is Obamacare Paid for?

The main new source of revenue for Obamacare has nothing to do with Medicare. Beginning next year, there is a new 3.8% tax on “unearned” income, such as capital gains, dividends, and interest income, for those with total incomes over $200,000 per year ($250,000 for couples). This is coupled with a 0.9% increase in the Medicare tax on earned income over $200,000/$250,000. These new taxes on upper-income taxpayers, though receiving little ink or airtime, are among the most important reasons why Obamacare has been targeted for repeal.

Other, smaller sources of revenue are a 40% excise tax on so-called “Cadillac” health plans (those having premiums over $27,500 per family); taxes on the pharmaceutical, insurance, indoor tanning, and medical device industries; and limitations on cafeteria-plan and health expense deductions.

Over the next ten years, Obamacare (including its associated taxes) is estimated by the Congressional Budget Office to result in net savings to the federal government of $109 billion. However, this does not include the cost of SGR repeal, the “crowd-out” phenomenon, employment migration due to the elimination of “job-lock,” increases in medical inflation, and other factors that are inherently difficult to predict and are outside the scope of this article.

Impact on Physician Practices

Most physicians will be impacted by Obamacare, regardless of their specialty and mode of practice. Combined with the subsidies for EHR in the HITECH Act, Obamacare will drive medicine toward more data-driven, technology-intensive, outcomes-oriented reporting in order to be eligible for contracting and payment. This has already begun in the Medicare system with PQRI and PQRS initiatives and is spreading to the private insurance sector. Additionally, the ACO initiative will likely accelerate the trend toward practice integration and buyouts by larger entities.

In fifteen months, approximately 30 million Americans will begin to enroll in Medicaid and subsidized private health insurance plans. Access problems, especially for Medicaid enrollees, are inevitable. Mandated managed care plans for Medicare-Medicaid dual-eligibles may accentuate this problem. Access problems may drive state legislation toward increased scope of practice for limited license practitioners in order to meet the increased need.

It should not escape physicians’ notice that “bending the cost curve” is aimed squarely at our profession. In addition to finding new ways to limit physician compensation, Medicare and private insurers will look to physicians to limit their use of costly diagnostics, pharmaceuticals, and procedures and to justify everything we do with outcomes reporting.

On the other hand, the health exchanges and subsidies will, for the first time, allow many working-class and middle-class families the opportunity to have real health insurance. We may be shocked in the next few years at the backlog of previously untreated patients who are now crowding our waiting rooms, and we may be gratified at our increased ability to provide the care that these members of our community need.

The challenges posed to our profession by Obamacare are real. We will need to become more efficient in the face of increased electronic documentation requirements and declining or stable reimbursements. However, physicians are resourceful and energetic people. Just as we have met the challenges of incorporating new knowledge and techniques and found ways to make the difficult transition from paper charts to computers, we will find ways to handle the transitions of the next few years as well. Regardless of legislative and electoral outcomes, the nation and our patients need our services, and the huge, dysfunctional, but ultimately homeostatic health care economy will find ways to adjust. Obamacare as enacted in 2010 is not the final word on the subject. By staying informed and uniting as a profession to advocate for fair, responsible solutions, we can help shape a positive outcome.

Dr. Andrew Calman practices ophthalmology at CPMC-St. Luke’s and teaches at CPMC and UCSF. He is past president of the California Academy of Eye Physicians and Surgeons, chair of the SFMS’s Political Action Committee, and served for many years on California’s Medicare Carrier Advisory Committee as well as the National Health Policy Committee of the American Academy of Ophthalmology.

SFMS Develops Updated Domestic Violence Guide for Clinicians; Covers Screening, Diagnosis, Documentation, and Reporting Protocols

Wed, 28 Nov 2012 12:23:56 GMT

Back by popular demand! The SFMS has updated and published a short guide on domestic violence screening and intervention for physicians and other clinicians in consultation with some of the most experienced clinicians in this arena.

Published in the December issue of San Francisco Medicine as an insert and also available on the SFMS website, this guide represents a concise and clinically based approach to this complex issue, distilling knowledge from existing, longer documents. Covered topics include:

Screening questions
Diagnosis
Intervention options
How to document medical records
Reporting protocol

The original guide has been widely distributed and well received by clinicians citywide and beyond, and it was cited in the Journal of the American Medical Association as one of the best such resources. This new version has been updated with current contact information and new information.

Click here to see the SFMS Domestic Violence Guidelines.

Obamacare—Past, Present, and Future, Part 3

Mon, 26 Nov 2012 15:51:41 GMT

By Andy Calman, MD, PhD

Note: This article was originally published in the October 2012 issue of San Francisco Medicine. Due to members' request for more information on health care reform and its impact on medicine, SFMS is publishing a four-part series in the SFMS blog section. Click here to read Part 2 of this 4-part series on Obamacare and its impact on U.S. physicians and patients.

Alternative Delivery and Payment Models

A large component of Obamacare is an attempt to “bend the cost curve” and reduce the rate of Medicare expenditure growth. There are several components to this, many of which have been greeted with skepticism from the provider community. It is worth noting that past efforts to limit Medicare spending through Medicare Plus Choice and Medicare Advantage (essentially HMOs and PPOs) have actually increased costs compared to traditional fee-for-service (FFS) Medicare. The HMO experiment has already been done twice and was a failure. However, most members of Congress are not well versed in the scientific method, are convinced that FFS is evil and rewards greedy providers, and are inclined to keep trying similar experiments in the hopes that this time they will actually work.

Currently, the Medicare Payment Advisory Commission (MedPAC) makes recommendations to Congress on changes to Medicare payment and program rules, but it has no power to enact such rules itself. However, beginning in 2014, the new Independent Payment Advisory Board (IPAB), dubbed “MedPAC on steroids,” will have the power to set Medicare payment rates and rules for the following year, and its rulings can only be overturned by a Congressional supermajority. The AMA and other physician groups have set the elimination or restriction of IPAB as a high legislative priority, as its powers are viewed by many as excessive and unchecked.

In addition to IPAB, Obamacare has established a Patient-Centered Outcomes Research Institute to perform comparative effectiveness research. Its recommendations may be considered by CMS but are not binding. There is also a new Center for Medicare and Medicaid Innovation within CMS, which is tasked with overseeing new delivery and payment methods in order to improve care while lowering costs.

Obamacare also sets up new entities dubbed Accountable Care Organizations (ACOs), which are groups of providers who contract to provide care for Medicare FFS beneficiaries. These ACOs may include individual providers, IPAs, and/or hospitals. ACOs will, in theory, be rewarded financially for quality and efficiency of care. The initial response from the medical community was lukewarm, with few groups willing to accept the downside risk of bidding for ACO contracts.

In response, CMS released updated ACO guidelines in 2011, which streamlined the organizational and reporting requirements and limited the downside risk. Whether ACOs will be a successful component of Medicare remains unknown, but the larger local IPAs, HMOs, and hospital chains can be expected to organize and compete in this arena in the years to come. Individual providers may feel compelled to join with larger entities in order to retain their patient bases and remain viable.

Obamacare has also set up a new Federal Coordinated Health Care Office, targeting dual-eligible Medicare-Medicaid beneficiaries, primarily the low-income elderly and disabled, for cost savings. States are encouraged to set up programs to integrate care for these beneficiaries. California, at the behest of Governor Brown, has requested a CMS waiver to expand an existing “pilot project” from four counties (including Los Angeles) to involve the entire state. This project, opposed by CMA, would force California’s low-income seniors into managed care, with a six- or twelve-month “lock-in” provision. Physician fees and access to dual-eligible patients may be severely affected, even though most of the savings from such a forced migration would probably come from long-term care rather than physician services.

What about the SGR?

One of organized medicine’s highest priorities for the past several years has been the repeal of the Sustainable Growth Rate (SGR), which adjusts aggregate Medicare physician payments based on the gross domestic product rather than the actual demographic growth rate of the Medicare population, the medical inflation rate, or the cost of new technologies. As a result, medicine faces an annual threatened payment reduction of about 30%, which is usually averted at the last minute by Congressional action, often after a temporary payment cutoff to physicians.

It is worth noting that the House of Representative's version of Obamacare, championed by our own member of Congress and by House Democrats, contained a complete repeal of SGR and was generally much more favorable to physicians. However, it was the Senate version that prevailed (after the election of Senator Scott Brown provided a forty-first vote for a filibuster, and the final Senate bill was amended through reconciliation), and Obamacare as passed did not address the SGR. The main reason for this is that keeping the SGR in the payment formula allows Congress and the administration to maintain future cost estimates that are artificially optimistic, while averting drastic payment cuts in an annual Congressional drama. However, there is no guarantee that a future Congress, in a deficit-cutting mood, will continue to avert these annual SGR disasters.

ICD-10: Everything You Know Is About To Change

Mon, 12 Nov 2012 15:23:56 GMT

The transition to ICD-10 is one of the most daunting regulatory requirements ever imposed on physicians. Not only will the number of diagnosis codes dramatically increase from 16,000 ICD-9 codes to 68,000 ICD-10 codes, new formatting and documentation requirements will impact numerous medical office processes and personnel. While the compliance date for ICD-10 implementation of October 1, 2014 may seem far away, physicians are encouraged to start planning for ICD-10 and 5010 transition immediately.

About ICD-10

ICD-10-CM/PCS (International Classification of Diseases, 10^th Edition, Clinical Modification/Procedure Coding System) consists of two parts:

ICD-10-CM is for use in all U.S. health care settings. Diagnosis coding under ICD-10-CM uses 3 to 7 digits instead of the 3 to 5 digits used with ICD-9-CM, but the format of the code sets is similar.

ICD-10-PCS is only for use in all U.S. inpatient hospital settings. ICD-10-PCS uses 7 alphanumeric digits instead of the 3 or 4 numeric digits used under ICD-9-CM procedure coding. Coding under ICD-10-PCS is much more specific and substantially different from ICD-9-CM procedure coding.

Who Needs to Transition

ICD-10 will affect diagnosis and inpatient procedure coding for all health providers covered by HIPAA. Everyone covered by HIPAA who transmits electronic claims must also switch to version 5010 transaction standards. The change to ICD-10 does not affect CPT coding for outpatient procedures.

ICD-10 diagnosis codes must be used for all health care services provided in the U.S. on or after October 1, 2013. Claims with ICD-9 codes for services provided on or after October 1, 2014 cannot be paid.

Training

SFMS/CMA have partnered with AAPC, the nation’s largest medical training and credentialing association, to offer ICD-10 training to our members. Join us on December 5, from 12:15 pm to 1:45pm, for a free webinar about ICD-10 and how it will impact your practice. Topics covered include:

Key differences between ICD-9 and ICD-10
Scope of ICD-10 transition in a typical medical practice
Key steps in planning a successful transition
Resources to assist you

Click here to view the list of ICD-10 webinars/workshops available to members.

Additional Resources

General ICD-10 Information

CMS-0013-P—HIPAA Administrative Simplification: Modification to Medical Data Code Set Standards to Adopt ICD-10-CM and ICD-10-PMS

Transactions and Code Sets Regulations

ICD-10 Basics for Medical Practices

Talking To Your Vendors about ICD-10 and Version 5010 - Tips for Medical Practices

ICD-10 Transition FAQs

Medi-Cal Requiring Physician Re-enrollment

Fri, 09 Nov 2012 11:51:53 GMT

The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA). The ACA requires every state Medicaid program (Medi-Cal in California) to revalidate provider enrollment information at least every five years beginning January 2, 2013.

DHCS is currently working to identify an initial list of all physicians and other providers who will be required to revalidate. Notices of revalidation will be mailed beginning the second week of January 2013. Notices will be sent to business location on file with DHCS. Each notice will include information on which application(s) must be completed. Anyone receiving a notice must complete and return the requested form(s) and required attachments within 35 working days of the date of the notice. Failure to do so may result in payment delays.

Physicians, who have revalidated, updated, or submitted new applications to the Medicare program within the last 12 months (January 1 through December 31, 2012) will not be required to revalidate at this time. However, your Medicare enrollment information must match the information on file with the Medi-Cal program. If the information does not match, you will receive notice from DHCS requiring you to revalidate.

SFMS/CMA will be hosting two live webinar training courses with representatives from DHCS to walk attendees through the Medi-Cal enrollment process for both individual providers and groups. Also to be discussed will be program requirements and how to avoid common mistakes that can lead to delays, denials and exclusion from the Medi-Cal program. These extended-length webinars are free to members, and will be held November 15, 2012, and January 16, 2013, from 12:15 to 1:45 pm.

Click here for more information or to register for the complimentary webinar(s).

Anthem Blue Cross Amends Physician Contracts to Include Individual/Exchange Product; Resources/Assistance Available to SFMS Members

Tue, 06 Nov 2012 13:28:21 GMT

On October 24, Anthem Blue Cross sent a notice to 8,345 physicians who are part of the Blue Cross Select PPO network announcing its intent to participate in the California Health Benefit Exchange, the state’s new insurance marketplace called for under the Affordable Care Act. Beginning in 2014, individuals and small business will be able to purchase health insurance using tax subsidies and credits from the exchange.

According to the notice, Blue Cross will be creating a new provider network called the “Anthem Individual/Exchange Network,” which will serve both individuals who purchase coverage through the exchange and individuals who purchase coverage from Anthem Blue Cross in the individual market outside of the exchange. In other words, the fee schedule would apply to all individual business, whether bought on or off of the exchange.

Blue Cross has clarified for the SFMS/CMA that this fee schedule change will not apply to Small Business Health Options Program (SHOP) business purchased through the exchange.

It’s important to note that Blue Cross is amending the physician’s Blue Cross Prudent Buyer Agreement to automatically include the new individual/exchange network, effective January 1, 2014. The new fee schedule associated with this product was included with the notice.

SFMS/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. Click here for more information about contracting with exchange plans.

Individual/Exchange Network Opt-Out

Physicians can opt out of the individual/exchange network by notifying Blue Cross of their intent to opt out by December 31, 2012. Opt out notices should be in writing and sent via certified mail, return receipt to the address specified in Section VI of the amendment. Sections VI and VIII of the contract amendment provide instructions for physicians who wish to opt out of the individual/exchange network.

Please note that a small subset of Select PPO Network physicians did not receive the October 24 notice automatically opting them into the individual/exchange network. This subset of physicians received a notice from Blue Cross dated October 9 regarding fee schedule reductions. Physicians who choose to discontinue participation in the Select PPO network at the reduced rates have until December 14 to notify Blue Cross in writing.

Physician Status Inquiries

Physicians who did not receive a letter and are unsure whether they are affected by this change or those who have general questions about the amendment can contact Blue Cross’s Network Relations Department at (855) 238-0095 or networkrelations@wellpoint.com.

Assistance with Anthem Blue Cross Contracts

SFMS members can receive one-on-one assistance by contacting CMA staffers Mark Lane (916) 551-2865 or Jodi Black (916) 551-2863.

Health Plan Contract Analyses

As part of your member benefit, SFMS members enjoy free access to objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification.

Log into the SFMS website to view/download the Blue Shield Provider Agreement analysis, updated in September 2012. To access the member-only section for the first time, please use your license number as the username and the first name initial and full last name as the password. For example, Dr. John Doe’s password would be “JDoe.”

Click here to view analyses for Anthem Blue Cross of California Prudent Buyer Plan, Health Net, and United Healthcare. Please note SFMS/CMA is currently updating contract analyses for each of the California major health plans. Updated analyses will be posted on the SFMS website when they are available.

Step-by-Step Guide to Payor Contract Negotiation

SFMS/CMA have developed a step-by-step guide to assist physician members through the contract evaluation and negotiation/renegotiation process. Click here to view/download the free membership-only guide after logging into the SFMS website.

Member Helpline with Health Plan Contracting Issues

SFMS members are encouraged to contact our complimentary member reimbursement help line at (888) 401-5911 or economicservices@cmanet.org for personalized assistance with contracting issues.

Should You Sign the New Blue Shield Agreement?

Mon, 29 Oct 2012 17:16:56 GMT

The California Medical Association (CMA) continues to receive a high volume of calls from physicians and their staff regarding the new Blue Shield contracts. However, more recent reports from physicians indicate that Blue Shield representatives have become more aggressive in their attempts to get physicians to sign the new contracts.

Click here to view an in-depth analysis of the new contract (login required). SFMS/CMA has also prepared answers to the most common questions received from physicians about the new contracts:

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 SFMS/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.

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.

What happens if I do not sign and return the agreement by the date requested?

Blue Shield has indicated that if a physician chooses not to sign the new agreement, his or her current participation status with Blue Shield will not be affected.

Blue Shield has advised SFMS/CMA, however, that physicians who do not sign and return the new agreement will receive follow-up calls and letters from Blue Shield representatives encouraging them to sign the agreement and return to Blue Shield.

It’s important that physicians understand if they do not wish to participate in the new tiered networks offered in anticipation of the Exchange or any other product types offered, they are not required to sign and return the new agreements. Their current participation status will not change.

Physicians who want to participate in the new tiered networks will need to decide whether they wish to opt out of any product types and affirmatively do so by checking those product type boxes in Exhibit A number 2, then sign and return the agreement to Blue Shield. As indicated in Exhibit A number 2, by checking the box the physicians is stating he/she does NOT agree to participate in that product. A box left blank indicates the physician AGREES to participate in that product.

If you are a SFMS member requiring assistance with Blue Shield contracting, please contact our toll-free reimbursement helpline at (888) 401-5911 or email economicservices@cmanet.org.