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.

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

1. 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.
2. 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.
3. COLLECT specimens for testing and, after obtaining approval from SFDPH Communicable Disease Control, send specimens to SFDPH Public Health Laboratory per instructions below.
4. 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.
5. 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. 

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.

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.

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.