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.

Stephanie Oltmann, MD is a board-certified family physician with the Dignity Health Medical Group – Saint Francis/St. Mary’s.

A native of Germany, Dr. Oltmann spent an intern year in Neurology, worked as a house officer in Australia and the U.K. specializing in urgent care and emergency medicine, and completed her residency in Family Medicine in Long Island, NY, where she also served as chief resident. Her special clinical interests include neurology, chronic disease management, preventive care and travel medicine. To view Dr. Oltmann’s practice information, please click here. 

I am a SFMS member because I believe the SFMS is one of the best ways that we, as physicians, can stay informed and engaged with each other and active as a community resource on issues of health, wellness and better living.

Which SFMS member resource is most helpful to you?

The most helpful resource in the medical society is the membership. Whether it is learning from other members about how to meet the professional and personal challenges that physicians often face, or hearing from others about career directions that I never thought possible, I get more out of being a physician by being part of the organized physician community.

My greatest achievement outside of practicing medicine was helping a young person, who delayed becoming a physician in order to work and support his family, return to school and successfully apply to and graduate from medical school. After years of hard work, presenting him with his own doctoral hood was more satisfying than the day I was presented with my own.

What is the most important thing you learned in medical school or residency?

I was once advised that, in order to achieve personal balance, I should always pursue my life, outside of medicine, with the same intensity that I’ve pursued my medical career. Since finishing residency, I’ve gone back to school to study art and foreign language, ran for public office, maintained pre-med school friendships and started new ones with people who know me from the local community or the interest group, not the clinic. This has helped me avoid professional burn out and make medicine that fun thing I do, when I’m not working hard at enjoying the rest of my life.

What are some of the biggest opportunities or challenges you see in health care within the next five years?  

Moving this country from a “health cost system” to a “health care system” will either be the biggest challenge to us, or the biggest opportunity for us. It will be difficult, but we must decide if health care in this country is going to be an economic privilege or a human right and how best to make the path we choose a viable and sustainable reality for everyone.

I love practicing Family Medicine because I love that my clinics are in the neighborhoods and communities where I live and am also active in. Most of my patients come from the local area around the clinics, so I get to know them and their families, not just as patients, but as neighbors, too. It’s like being a small town doctor…in a big city!

What is your favorite restaurant in San Francisco?

I admit, on special occasions, I treat myself to a Bacon Double Del Cheese Burger at the Del Taco fast food restaurant on Market Street. I think it’s the special sauce that makes it taste so good!

If I wasn't a physician, I would likely ended up a comic book or animation artist. It’s the other thing I’m good at.

By Toni Brayer, MD

The way doctors bill and get paid is a byzantine process and it is no wonder the "private practice" doctor is an endangered species. It takes a keen sense of business, a love of medicine-not money, and a sense of humor to survive. Here is my latest story. You can't make this stuff up....

I saw a patient in September 2001 (note the date...11 years ago). I billed her insurance company, Employers Mutual, LLC for $185.00. I never got paid.

Now fast forward to September 2012. I received a document from an attorney who informs me that he is a receiver in a class action suit and $48 million in unpaid claims is being claimed. It appears I am a Category B creditor and will receive a pro-rata share. He recovered $16, 559, 576.88 and took $4,831,214.40 in attorney fees.

It looks like in the future (?) I may receive a check for $37.00. No promises are given.

I remember my practice back in 2001. I worked about 80 hours a week and never even had enough money to fund a retirement plan for myself.  Getting paid a fraction of my charges was common and getting stiffed by insurers completely was also par for the day.

I am happy for the windfall of $37.00 for the work I did 11 years ago. I still see patients in a private practice but my main income now comes from my employed administrative position. Waiting 11 years for a fraction of payment is not a sustainable business model.

Toni Brayer is an internist who blogs at EverythingHealth. 

Originally published in EverythingHealth on September 7, 2012. 

Healthy men should no longer have PSA measurements as a screening test for prostate cancer, according to a final recommendation from the United States Preventive Services Task Force (USPSTF).

The so-called grade D recommendation applies to men of all ages but does not apply to the use of PSA testing for monitoring patients after a prostate cancer diagnosis or treatment.

Calling prevention of prostate cancer deaths the primary goal of screening, the task force cited a lack of evidence that PSA testing has an impact on that goal.

The USPSTF based its recommendation largely on data from two large trials of PSA screening for prostate cancer. One trial showed no difference in prostate cancer mortality between screened and unscreened men. The other showed an adjusted reduction in mortality risk of 29% among screened men, which the USPSTF translated into too few lives saved to offset the potential harms of screening.

The American Cancer Society weighed in on the issue, and generally supported the USPSTF decision.

The American Urological Association also responded. The AUA vice chair of the health policy council David Penson, MD, said the recommendation was not unexpected but was nonetheless disappointing.

Click here to view the full USPSTF recommendation statement on prostate cancer screening.

Click here to view the full article.

Source: MedPage Today, May 21, 2012.

Medi-Cal primary care physicians will receive a two-year, $11 billion pay increase, under a proposal released last week by U.S. Department of Health and Human Services. The proposal, which implements a provision of the Affordable Care Act (ACA), would on average result in a 50 to 60 percent increase in Medi-Cal rates for primary care physicians, including family medicine, pediatrics and internists, plus related subspecialties. The ACA calls for Medicaid payments to primary care physicians to be raised to Medicare levels for 2013 and 2014.

The increase, effective in 2013 and 2014, bring Medicaid payments to primary care physicians in line with those for Medicare. Although Medicaid is jointly funded by states and the federal government, the increase would be paid for entirely by the feds.

“The payment increase proposed today will be an important tool for states to ensure their primary care networks are prepared for increased enrollment as the health care law is implemented,” said Marilyn Tavenner, Acting Administrator for the Centers for Medicare & Medicaid Services (CMS), in a statement issued last Wednesday. “Today’s action will help encourage primary care physicians to continue and expand their efforts to provide checkups, preventive screenings, vaccines and other care to Medicaid beneficiaries.”

SFMS/CMA have been working closely with CMS to ensure that the definition of primary care used is as broad as possible. We believe this two-year pay increase is a step in the right direction; however, it is critical that we find a long-term solution that will ensure that the influx of new Medi-Cal patients will be able to find a doctor.

SFMS/CMA believe the two-year pay bump will prevent many primary care physicians from leaving the program, but it may not be enough to attract new physicians. Some primary care physicians will not want to enroll in the program and establish patient relationships, only to have to pull out in two years and leave their patients, she says.

Currently, California’s rates rank 47th in the nation and are on average 50 percent below Medicare rates. Because of these low rates, two-thirds of California’s physicians cannot afford to participate in the program and more than 50 percent of Medi-Cal patients report they can’t find a doctor.