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.

On April 1, 2013, UnitedHealth Military & Veterans Services (UMVS) began providing managed care services to 2.9 million TRICARE beneficiaries in the 21 western states, including California. On that date, UVMS took over the contract previously held by TriWest. Since then, the California Medical Association (CMA) has received reports from physician practices that have experienced various problems during the transition.

Your feedback is very important! The results of this survey will help CMA identify areas of concern, escalate those issues to UMVS and ensure the problems are addressed and resolved quickly.

Please share your experience! Click here to respond to our brief survey or visit http://www.surveymonkey.com/s/TRICAREtransitionsurvey.

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. 

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.

By David Kornguth, MD

As a physician at Golden Gate Urology (GGU), I see the human toll of prostate cancer on a daily basis. All of us at GGU seek to help patients and their families stay healthy. This is the reason why my colleagues and I decided to sponsor an event benefitting men and their families who face prostate cancer and draw awareness to prostate cancer prevention and screening.

The ZERO Prostate Cancer Run is the first Bay Area prostate cancer run. It’s part of the ZERO Prostate Cancer Challenge, that brings together athletes, physicians, cancer survivors, and those who care about them to help fund research to end prostate cancer and to provide free testing and education.

The June 15^th event includes fun and interactive activities to educate and raise awareness of the disease. In addition to the 5K run/walk, we are organizing a shorter walk that allows patients to learn about prostate cancer in a healthy environment.

At GGU, our vision is to lead the transformation of health care in the bay area by partnering with patients, doctors and researchers in providing better urologic care and enhanced patient education as we strengthen our community outreach to create a lasting positive impact in our field. We want men to know the truth about prostate cancer treatment so their lives are healthier and enjoyable. For those with prostate cancer, we want to cure them. 

Prostate cancer is the most common cancer found in men with over 200,000 men diagnosed each year. Fortunately, most men are diagnosed with early stage prostate cancer and can be cured. A simple blood test called a PSA can help find even early prostate cancers. PSA tests save lives, yet many men do not get screened. If more men learn about modern treatment techniques and the truth about prostate cancer, fewer men will die or develop disability because of advanced prostate cancer.

The goal of the ZERO Prostate Cancer Run is to promote prostate cancer education and prevention. I hope you will consider joining GGU and fellow colleagues in this event.

Click here for event details. 

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All Golden Gate Urology physicians based in San Francisco are members of the San Francisco Medical Society. To find a SFMS member physician by location, specialty, type of insurance accepted, and more, please use the SFMS Physician Finder, a free service provided by the SFMS.