As previously reported, CMA has received numerous complaints from physicians regarding Blue Cross and Blue Shield’s refusal to honor assignment of benefits, highlighting the burden and cost it places on the physician practice to act as debt collectors rather than physicians, and in many cases, this policy has jeopardized the physician-patient relationship.      

To address this issue, CMA sponsored AB 1742 (Pan) to shore up this loophole and require Blue Cross and Blue Shield, the major PPOs currently refusing to honor assignment of benefits, to pay physicians directly for out of network services.  

Representatives of Blue Cross and Blue Shield were asserting to the legislature a false claim that by removing the incentive of direct pay to the physician for out of network services, there would be a broad erosion of the PPO networks. In other words, they asserted that direct pay is the main reasons physicians decide to contract and if that option is removed, doctors will no longer contract with payors.

CMA/SFMS conducted a survey on criteria physicians consider before signing a contract to be in a payor network. We had an overwhelming response to the survey, gathering over 1,100 responses from physician practices in 43 different counties within a very short period of time.  Through the survey results, we were able to highlight the following to the legislature:  

• The two most important factors physicians consider when deciding to join a payor network are fair reimbursement rates (78%) and low administrative hassle factor (35%) followed by fair contract terms/language (34%) and a payor’s market share in the area (28%). Only 5% of physicians report that the guarantee of direct payment from the payor is deciding factor.
• More than 8 in 10 physicians report that the payor’s policy of paying patients directly for out-of-network services has had a negative impact on patient care.
• Almost 100% of the respondents who experienced an instance of the payor paying the patient directly reported difficulty collecting from the patient.   
• The failure of Blue Cross and Blue Shield to honor assignment of benefits is extremely costly for physician practices.  96% indicated there was a negative financial impact to the practice to collect from patients (e.g., lost revenue, administrative costs to collect, collection agency fees, lost follow-up business, etc.) when a payor refuses to honor assignment of benefits. 49% reported the financial impact of a payor sending payment directly to the patient is greater than $5,000 and 14% report it costs their practice more than $20,000 to try to collect when payment is sent to the patient.   

Though this specific bill is still in the Assembly Health Committee for reconsideration after failing passage earlier this week, our effort to require Blue Cross and Blue Shield to honor assignment of benefits will continue.  The survey results will also aid our legislative efforts in support of physicians and patients on various issues.

Click here to view the comprehensive survey results. 

SB 1318 (Wolk), which would require all health care workers in health care facilities, including physicians, to either receive the influenza vaccination or wear a mask in patient care areas during flu season, moved out of the Senate Labor and Industrial Relations Committee this afternoon. The bill is co-sponsored by SFMS/CMA.

Influenza is a contagious respiratory illness caused by influenza viruses. It can cause mild to severe illness and, at times, can lead to death. Some people, such as seniors, young children and those with certain health conditions, are at high risk for serious flu complications. SB 1318 will help to keep the numbers of hospital-acquired flu fatalities low. 

"The bill would protect our most vulnerable patients—infants, seniors and those who are immune-compromised," Wolk said. "It would ensure that health care workers receive the influenza vaccination, or wear a mask during influenza season. It's a choice: Get vaccinated, or wear the mask. We want to decrease the deaths from influenza, and increase the safety at hospitals." 

In California, several counties (Sacramento, Yolo and San Francisco) and numerous hospitals have gone beyond state law and have instituted mandatory vaccination policies that include a masking requirement for the unvaccinated. The California hospitals with the highest vaccine compliance rate are those that have such policies in place. 

SB 1318 passed the Senate Committee on Health and Labor and Industrial Relations, and is re-referred to the Committee on Appropriations.

On June 1, 2011, California began its transition of seniors and persons with disabilities (SPD) from Medi-Cal fee-for-service program into managed care plans, and will continue over the next several years until complete. Almost immediately, SFMS/CMA began receiving a wide range of complaints and reports of serious problems involving disruption of patient care.

 

Over 50 percent of Medi-Cal patients involved in the initial phases of the transition had been automatically assigned to health plans due to failure to respond to notices during the enrollment period. Was this truly the patient’s fault? Or was this the result of poor planning, lack of communication or other language barriers? Nonetheless, CMA has received numerous reports of patients losing access to physicians who cared for them for many years, and have also received an increasing number of complaints of plans and IPAs/medical groups refusing to contract with physicians who have been long time Medi-Cal providers.

 

While CMA has continued to work with the Department of Health Care Services (DHCS) to address those issues, the state now is seeking approval from the Centers for Medicare & Medicaid Services (CMS) to shift “dual eligibles” (persons with Medicare and Medi-Cal coverage) into Medicare and Medi-Cal managed care plans in four counties including Los Angeles, Orange, San Diego and San Mateo on January 1, 2013. If the state plan is approved by CMS, patients will begin receiving enrollment notices on October 1 through November 31 of this year. Furthermore, the state is once again seeking authority to automatically enroll individuals who do not actively enroll or opt-out within the required time frame.

 

The state’s plan is currently in a thirty (30) day public comment period. CMA is collecting data on the extent of problems and other issue physicians and their patients have experienced thus far. Examples of delayed and/or denied medical treatment, disruption in continuity of care, and other issues that negatively impacted the financial viability of your practice can be extremely powerful.

 

Your participation in this survey is crucial. The information you provide will be reflected in CMA’s response to the state’s proposal and will help us better advocate for solutions.

 

Click here to take the survey.

CMA is sponsoring AB 1742 (Pan), that would shore up a loophole in the law and require Blue Cross and Blue Shield PPO products to honor assignment of benefits and pay physicians directly. Currently, all other PPOs are required to honor assignment of benefits, and we are seeking parity in that law.

CMA is in the midst of a legislative struggle with representatives of Blue Cross and Blue Shield about what criteria physicians consider before signing a contract to be in a payor’s network. The plan representatives are successfully asserting a false claim about what drives physicians to contract. We need physicians’ help to refute this.

Please share your experience by responding to our brief survey at www.surveymonkey.com/s/2N3RCLH. The results of this survey will be crucial in helping us pass legislation to protect physician and patient interests.

It is critical that we receive your response no later than Friday, April 6, in order to analyze and review the data prior to the Assembly Health Committee hearing.

Questions? Contact CMA’s reimbursement help line at (888) 401-5911 or jblack@cmanet.org.

This week, the court ruled that California Department of Health Care Services violated disclosure law in 2011 by refusing to provide background information on proposed Medi-Cal payment cuts with the California Medical Association (CMA).

The official signed judgment states that “documents exchanged between DHCS and the federal Centers for Medicare & Medicaid Services… are not subject to the deliberative process privilege claimed by DHCS.” The court also ruled that “the relationship between DHCS and CMS is fundamentally different from that involved in cases which have recognized a deliberative process privilege and any benefit derived from keeping discussions confidential is substantially diminished in this context.” The court ordered DHCS to release the documents that it gave to federal officials. The state has 20 days to appeal the decision or ask for additional time to explain why the documents should not be disclosed.

Background

In October 2011, CMS approved the state's plan to reduce certain Medi-Cal payments by 10%. State officials said that the cuts would save $623 million. In February, U.S. District Court Judge Christina Snyder granted a preliminary injunction to block the rate cuts on the basis that they could cause irreparable harm. Last year, CMA, California Hospital Association, and California Pharmacists Association filed a Public Records Act request to gain access to the state's supporting evidence that the Medi-Cal cuts would not harm beneficiaries' access to care. DHCS denied the request, saying that such documentation needed to remain private so the agency could "engage in candid policy discussions" with federal officials.