California Medical Association
In 2015, Covered California, California’s health benefit exchange, enrolled approximately 1.3 million individuals in qualified health plans. With Covered California estimating to add an additional 300,000 enrollees during the 2016 open enrollment period (running November 1, 2015, through January 31, 2016), it is critical that physician practices understand their participation status, which products are being offered, and what changes to expect in 2016. SFMS has compiled the following guidelines to assist physician members with Covered California in 2016.
Anthem Blue Cross and Blue Shield of California, both of which offered an EPO in certain geographic areas previously, will no longer be offering an individual/exchange EPO product in 2016. Instead, both plans will be offering PPO plans.
Blue Shield of California sent notice of the change to its Exclusive EPO provider network on October 15, 2015. The notice states there will be no change to the provider agreements or reimbursement rates. While the product type is changing, the provider network will not change. Patients who select the PPO product will only have access to the narrowed individual/exchange network, rather than the broader provider network. Enrollees who chose to transition the Blue Shield individual/exchange PPO product will receive new ID cards reflecting their new PPO plan.
Anthem Blue Cross will no longer be offering its EPO network in California for individual/exchange enrollees. There will be no change to the provider network or reimbursement rates.
With the change in some product types and the addition of two new health plans offering coverage for 2016, SFMS encourages practices to re-verify their participation status. Practices also should re-verify the participation status of the physicians and other providers (e.g., physicians, facilities, etc.) to whom they may refer patients using the plan’s online provider directory search.
When searching the provider directories, ensure the correct product type has been selected. You will need to check your participation status for each product type offered in your area (e.g., PPO, HMO, EPO, HSP), but you do not need to search every metal tier. For almost all product types, the “Bronze 60” metal tier can be selected as the default. Many plans are utilizing narrowed networks for the exchange, so the search results in a provider directory for a standard commercial PPO plan will likely differ from those of an exchange provider directory.
Practices can contact the plans directly with questions or concerns regarding physician participation status.
Click “Provider Search-Find a doctor.” After selecting a plan year and a location type, under “Filter by Plan/Network” Under “Covered California” select one of the following:
• EPO – PureCareOne Small Business (this is the SHOP product)
• HSP – PureCare Individual & Family Plans
• PPO – Small Business (this is the SHOP product)
In the search box under the green ribbon towards the top right of the page, enter the physician’s name and select “in Doctors.”
[carrier name] + [metal tier name] + [actuarial value (AV)] + [product type (e.g., EPO, HMO, PPO)]
For example, Anthem Bronze 60 EPO is the Anthem EPO plan offered under Covered California’s bronze tier.
SFMS is urging all physician practices to verify patients’ eligibility and benefits effective January 1, 2016. The beginning of a new year means exchange/mirror product calendar year deductibles and any visit frequency limitations start over.
Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan). With open enrollment, there may also be changes to patients’ benefit plans, or patients may even be insured through a different plan. This reinforces the importance of verifying eligibility each time the patient is seen. Additionally, verifying eligibility will alert the practice as to whether the patient is delinquent on paying their premium and/or is in the federal three-month grace period.
Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice, as your ability to collect decreases significantly after the patient leaves the office.
Thank you to all SFMS members who participated in this year's SFMS election. We are proud to announce the SFMS leadership for 2016.
President: Richard A. Podolin, MD, FACC (2015 President-Elect automatically succeeds to the office of President)
President-Elect: Man-Kit Leung, MD
Secretary: John Maa, MD
Treasurer: Kimberly L. Newell, MD
Editor: Gordon L. Fung, MD, PhD, FACC, FACP
Immediate Past President: Roger S. Eng, MD, MPH, FACR (2015 President automatically succeeds to the office of Immediate Past President)
Charles E. Binkley, MD
Katherine E. Herz, MD, MS
Todd A. LeVine, MD, MS
Raymond Liu, MD
David R. Pating, MD
Monique D. Schaulis, MD, MPH
Winnie Tong, MD
Mabel A. Chan, MD
Alice H. Chen, MD
David T. Duong, MD, PhD
Dawn D. Ogawa, MD
Robert J. Margolin, MD
Gordon L. Fung, MD, PhD, FACC, FACP
Shoshana R. Ungerleider, MD
Mark A. Schrumpf, MD
Ameena T. Ahmed, MD, MPH
Roger S. Eng, MD, MPH, FACR
Man-Kit Leung, MD (automatically serves in his capacity as SFMS President-Elect)
George A. Fouras, MD
Keith E. Loring, MD
Stephanie Oltmann, MD
Judy L. Silverman, MD
Daria L. Thompson, MD, MPH (Resident)
CMS released more than 1,300 pages of new regulations in October 2015 outlining requirements for the electronic health record (EHR) meaningful use program, with several changes applying this year. SFMS has gathered some of the most important changes that will affect your practice.
The regulations fall under two new rules—one that modifies Stage 2 of the meaningful use program and finalizes requirements for Stage 3, and one that establishes technological parameters for the new edition of certified EHR technology.
On the upside, the first rule eases and streamlines some of the requirements for Stage 2. But the rule simultaneously ignores clear calls from Congress and physicians to hold off on Stage 3 until the program is reassessed for practicality and alignment with new payment and delivery reforms.
Immediate improvements to Stage 2 include:
And while these are positive modifications, CMS didn’t release the final regulations until October 6—several days into the final 90-day period of the year. Equally as concerning, the regulations now require a public health and clinical data registry reporting objective that previously was optional.
So far, only 12% of physicians have met Stage 2 requirements.
Fortunately, physicians will have some recourse for avoiding penalties. Responding to requests from organized medicine, CMS has said that physicians who are unable to meet meaningful use requirements this year as a result of the delayed publication of the regulations can apply for a hardship exemption.
The AMA is encouraging physicians to apply for a hardship exemption under the “extreme and uncontrollable circumstances” category, even if they are uncertain whether they will meet the program requirements this year. Doing so will not preclude physicians from receiving an incentive if they do meet meaningful use requirements this year, but applying can serve as a safety net in staving off a penalty. The exemption application will be available early next year.
Under the rule, all physicians will be required to meet Stage 3 requirements beginning in 2018. The finalized rule as currently written would be very burdensome for physicians. Among the many mandates will be upgrading to EHR products that meet the new certification requirements. While CMS is allowing a 60-day comment period for feedback on the final rule, a groundswell of physician responses will be needed to change the proposal, given the complexities of the lengthy regulations already issued.
Physicians can visit BreakTheRedTape.org to submit their comments on the new rule to CMS and ask the agency to take action so that critical problems with the program are addressed before moving forward.
Also, physicians can join their peers in sharing their stories about how meaningful use regulations are affecting the patient-physician relationship.
A team of UCSF researchers led by Robert Lustig, MD published groundbreaking research on the impact of dietary sugar—and reduction thereof—in improving health. The paper is being widely reported in the media. The New York Times noted:
“Obese children who cut back on their sugar intake see improvements in their blood pressure, cholesterol readings and other markers of health after just 10 days, a rigorous new study found. The new research may help shed light on a question scientists have long debated: Is sugar itself harming health, or is the weight gain that comes from consuming sugary drinks and foods mainly what contributes to illness over the long term?”
The SFMS’ San Francisco Medicine journal featured an interview with Dr. Lustig earlier this year wherein he previewed the just-completed research.
Kory Stotesbery, D.O. is a Child and Adolescent Psychiatrist currently in private practice in San Francisco's Financial District and downtown Walnut Creek. He also works for the Seneca Family of Agencies in SF and Sonoma County where he provides care for youths identified through foster care and juvenile justice. He did his residency training in Adult Psychiatry at Thomas Jefferson University Hospital in Philadelphia and his Child Psychiatry Fellowship at Children's National Medical Center in Washington DC. His unique areas of interest are Eating Disorders and Childhood Trauma. He attended college at Arizona Statue University where he received his BA in Anthropology. His medical degree was received from the Philadelphia College of Osteopathic Medicine.
Dr. Stotesbery lives in Concord with his wife, Elizabeth, twin 15 month old sons, Jack and Ewan, and their chocolate Labrador, Piper. Only recently moving to the Bay Area 2 years ago, they all enjoy travelling and getting to experience the many things that make this the best place to live in the world!
Click here to view Dr. Kory Stotesbery's practice information.
Why are you a SFMS member?
Since finishing my training in child psychiatry and moving to the Bay Area I have been increasingly aware of the needs of the youth in our community. California as a whole has always impressed me with its capacity and embracement of political action and advocacy. In SFMS I found an organization that is enthusiastic and most importantly effective in its activism. The decision to join was easy as I felt that SFMS was the perfect way for me to be involved with making changes I am passionate about, learning more about needs outside my scope, and developing a network of colleagues with the same goals and values.
Which SFMS member resource is most helpful to you?
The wonderful magazine, San Francisco Medicine. I have already seen great value in the social functions that the Society organizes. At one such event I was able to meet a fellow psychiatrist, Dr. Eli Merritt, who is now my go-to referral for patients needing help navigating the healthcare system. There I also met a child psychiatrist who I now discuss cases with from time to time.
What do you like to do when you’re not at work?
My number one pastime is spending time with my family! My wife and I have identical twin infant boys and a 1 year-old Labrador. We do a lot together in the Bay Area- hiking Angel Island, digging in the sand at Stinson Beach, and travelling up to Sonoma for weekends in the country. We’ve also done a lot of travelling with trips to see family in Phoenix and New York. Even a Mommy-Daddy trip to Asia this past February!
What is the most important thing you learned in medical school or residency?
That’s easy!-- How to handle emergencies. A mentor once broke things down for me that if you can be confident in handling the most difficult situations, everything else is a walk in the park. It has allowed me to focus my practice on working with some high-risk populations—Eating Disorders and Foster Care Mental Health. While the chance of emergency is higher than other populations, the work is the most fascinating and rewarding experience I’ve had in medicine.
What are some of the biggest opportunities or challenges you see in health care within the next five year?
For me it is the stigma that is associated with mental healthcare. Our world is becoming more aware and comfortable with mental illness every day. What used to be something people only talked about in private settings or laughed at in movies and television is now a public issue. Too often people hold mental illness in a negative light even though in large part it is no different than any other medical illness. Still the bottom line is that there are constructs that exist in our society that drive people away from getting the care they need. People are hesitant to trust that our system will protect their confidentiality. They want to make sure they have that trust because they fear shame if people find out they have something in their lives they need help with. It would be great if some day people could be as proud of seeing a therapist as they are of going to a personal trainer. Within our field I also think mental health providers need to do better job of practicing responsible care so that we can earn the same trust providers in other fields are generally afforded.
What do you love most about practicing psychiatry?
I am absolutely fascinated by the role emotions play in the mind. The idea that our mind can be so complex that a person can undergo stress and become temporarily blind or even paralyzed amazes me. On the other hand, we are also so simple that many of the reasons why things happen in our lives are best explained by simple animal behavior models. So much of my day is filled with pondering those thoughts about my patients’ lives. While all that theory and analytic thought is great, my work also allows me to execute the treatment. There aren’t many fields of medicine left where the doctor has a unique skill in treatment that they use to deliver the treatment that directly helps their patients get better.
What is a special talent that you have?
I think the word talent assumes you are good at something so I can’t say I have a talent but I really enjoy screenwriting and acting. In college while my friends were using electives for Acting 101 I was using them for Organic Chemistry. Such is the plight of the pursuit of medicine. In medical school I put together a 3 hour sketch-comedy show for charity. It might have been the most fun I’ve ever had.
What is your favorite restaurant in San Francisco?
This is so hard! If I could live at The Tipsy Pig in the Marina I would… that backyard patio is the definition of Northern California. However I think I have to go with Suppenküche in Hayes Valley. I’m a dual German-American citizen so the experience of sitting elbow to elbow for great food is right at home. I think it is the only place that does German cuisine and culture correctly. They don’t do the whole Oktoberfest knock-off thing. However they do need to consult with my Oma about how spӓtzle is correctly prepared.
If you weren't a physician, what profession would you like to try?
Since we are only talking about TRYING a profession, I would like to try being Dick Proenneke from “Alone in the Wilderness.” If I can find someone with an off-the-grid cabin I can borrow it may be time for a sabbatical.