Sunday, April 20, 2014

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Providing news to the San Francisco Medical Community.


New Anthem Blue Cross Exchange Addendum: What Physicians Need to Know

Anthem Blue Cross recently notified over 11,000 practices who are currently participating in its individual/exchange network of a contract addendum that will become effective July 1, 2014. The amendment only applies to physicians who are currently participating in the Anthem Blue Cross individual/exchange network.

According to the notice, the addendum contains new regulatory requirements. While many provisions are requirements of Covered California, SFMS/CMA has concerns with certain provisions that appear to be beyond the scope of regulatory requirements, including:

  • Section 7 contains a broad requirement that physicians participate in any existing or future quality initiatives of Anthem or Covered California. While Covered California does require qualified health plans (QHPs) to report on a number of quality measures, SFMS/CMA is concerned that this broad provision could require physicians to comply with overly burdensome and/or costly requirements in order to meet current or future quality program criteria. Additionally, there are no exceptions if a physician is unable to comply with or report various quality or other performance measures.
  • Section 12 removes a participating physician’s ability to opt out of the individual/exchange product without affecting the underlying Prudent Buyer contract. Effective July 1, the only option for physicians who wish to opt out of the individual/exchange product is to terminate the underlying Prudent Buyer PPO agreement.
  • A provision in Section 10 allows Anthem to share providers’ contracted rates with Covered California. While Covered California does require QHPs to provide access to provider rates as of July 2014, SFMS/CMA has expressed concern with Covered California about the intended uses of this data.

Physicians have the right to opt out of the Anthem exchange product without affecting the underlying Prudent Buyer PPO contract if Anthem receives notice before the effective date of the addendum, July 1, 2014. If you do not wish to participate in the individual/exchange product, you can opt out by providing 90 days written notice, which should be sent via certified mail with return receipt, to Anthem Blue Cross Prudent Buyer Plan Contract Processing, Attn: Individual/Exchange Contract Processing, Mail Station 8A, P.O. Box 4330, Woodland Hills, CA, 91365-4330. The notice must be received by Anthem by June 30.

Please cc CMA on any opt-out notices submitted to Anthem at the following address:

California Medical Association
Center
for Economic Services
1201 J Street, STE 200
Sacramento, CA 95814

Physicians are as always urged to carefully review and assess the impact any contract changes or addendums will have on their practices. Questions and concerns about the Anthem exchange addendum should be directed to the Anthem Blue Cross Network Relations at (855) 238-0095 or networkrelations@wellpoint.com.


Free Risk Assessment Tool to Help Ensure HIPAA Compliance

Physicians in small to mid-sized practices can conduct their own risk assessments using a free tool newly available from the U.S. Department of Health and Human Services.

The security risk assessment (SRA) tool is designed to help practices conduct and document a risk assessment to evaluate potential security risks in their organizations under the Health Insurance Portability and Accountability Act (HIPAA) Security Rule. Conducting an SRA also is a core requirement for physicians seeking payment through the federal meaningful use program for electronic health records.

Physicians can watch a tutorial and other videos about risk analysis and contingency planning to provide further context. The assessment tool is available through the Apple App Store (search for “HHS SRA tool”) for use on iPads, and can be downloaded onto computers running Windows operating systems.

HIPAA regulations were updated last year in what were called the “most sweeping changes” since the law was implemented.

Click here for additional resources from the AMA to help physicians ensure their practices are HIPAA-compliant, including a new HIPAA toolkit and an associated continuing medical education activity.


CMS Releases Medicare Physician Payment Data

Last night, the Centers for Medicare and Medicaid Services (CMS) publicly released Medicare physician payment data, which identifies 38 of the top-paid doctors practice in California. The spreadsheet files show each physician’s NPI, name and address, average charge and Medicare payment amounts, unique beneficiary counts, and other information for the various Medicare services they provide. Although both federal officials and advocacy groups say the information will increase transparency, they also caution against misinterpreting the data.

CMS explained their decision to release the data in a letter to the American Medical Association (AMA). They cited that because of a recent court decision to reverse an injunction that previously prevented CMS from making the data available to the public, the agency received a large wave of Freedom of Information Act (FOIA) requests for data in which CMS felt could not be handled on a case-by-case basis. Given the broad interest in viewing the data, the agency determined that it should be made public and accessible to all.  Similar information has been available for several years on Medicare hospital payments.

Unfortunately, the data posted by CMS is not subject to safeguards that protect physicians and patients from misuse of inaccurate or misleading data.  Physicians were not given the opportunity to review their data for accuracy prior to their publication, and users of the data are not required to disclose the methodology they use in manipulating it.  Furthermore, the posted data has significant limitations.

A fact sheet is being circulated by the AMA to help promote responsible use of the data.

The AMA is in the process of examining the data to identify any additional issues and is exploring opportunities to help physicians respond as individuals to inquiries they may receive about their personal data. 

Click here for AMA's most recent press statement on the data release.


SFDPH Health Advisory: Measles – Consider measles in patients with fever and a rash

California is currently seeing increased cases of this highly infectious viral illness. Between January 1, 2014 and March 28, 2014, 49 cases of measles were reported to the California Department of Public Health, as compared with only 4 cases during the same period in 2013.

As of April 4, San Francisco has had no confirmed 2014 measles cases, though recent cases have occurred in several Bay Area counties. The majority of the 2014 cases have occurred among returning international travelers and their contacts; the majority have also occurred in unvaccinated individuals. A current measles outbreak in the Philippines has led to imported cases, but measles is currently circulating in many countries outside of North and South America. 

What San Francisco clinicians should do

  • Suspect measles in a patient with a fever and a blotchy, maculopapular rash. Ask about immunization history and recent international travel or contact with travelers. 
  • If measles is suspected, implement airborne precautions immediately, including masking and isolating the patient.
  • Report suspected measles cases immediately to San Francisco Department of Public Health’s Communicable Disease Control Unit (CDCU) at (415) 554-2830. CDCU can provide advice concerning specimen collection, expedited testing, infection control, and isolation. In addition, CDCU will undertake a contact investigation to identify and inform potentially exposed individuals. 
  • Review and document measles immunity for all office staff. SFDPH recommends vaccination of susceptible staff. 
  • Vaccinate susceptible patients, especially those at increased risk for measles, including health care workers, international travelers, women of childbearing age, and students in college or trade school. Although the MMR vaccine is routinely given at 12 months and 4-6 years of age, infants traveling to countries where measles is circulating can be vaccinated as early as 6 months of age.

For more information, go to sfcdcp.org/healthalerts.html.


New CMS 1500 Implementation Reference Guide

SFMS/CMA surveyed the major payors in California to learn about each payor’s requirement for submitting the new CMS 1500 (2/12 version) for submission after April 1, 2014.

With ICD-10 implementation delayed until October 2015, SFMS/CMA is awaiting additional information from CMS on whether there will be any changes to the new CMS-1500 form. Until that time, we recommend that providers continue to follow the previous guidance issued and implement as required. 

Payor Name
Requiring new CMS 1500 form effective 4/1/2014*
 Additional Information
Aetna  No Will allow practices to submit either CMS 1500 (version 08-05 or 02-12) after April 1, 2014. Aetna will require the new CMS form (02-12) beginning October 1, 2014. More information can be found at aetna.com.
Anthem Blue Cross
 Yes Require practices to submit new CMS 1500 (02-12) effective April 1, 2014. Any claims submitted on the old CMS 1500 form (08-05) will be rejected.
Blue Shield of California
 No Will allow practices to submit either CMS 1500 (08-05 or 02-12) after April 1, 2014. Blue Shield will notify providers at a later date as to when they will require use of the new CMS 1500 form (02-12). More information can be found at Provider Connection - Blue Shield of California.
Cigna  No Will allow practices to submit either CMS 1500 (08-05 or 02-12) after April 1, 2014. Cigna will notify providers at a later date as to when they will require use of the new CMS 1500 form (02-12). More information can be found at cigna.com, select "healthcare professionals," then select "Newsletters."
Health Net
 No Will allow practices to submit either CMS 1500 (08-05 or 02-12) until October 1, 2015.**
Humana  Yes Require practices to submit the new CMS 1500 (02-12) on April 1, 2014. Any claims submitted on the old CMS 1500 form (08-05) will be rejected.
Medi-Cal  Yes Effective April 1, 2014, DHCS will require practices to submit the new CMS 1500 form (02-12). Any claims submitted on the old CMS 1500 form (08-05) will be rejected.
Medicare  Yes Effective April 1, 2014, CMS require practices to submit the new CMS 1500 form (02-12). Any claims submitted on the old CMS 1500 form (08-05) will be rejected.
United Healthcare
 Yes Require practices to submit the new CMS 1500 form (02-12) on April 1, 2014. Any claims submitted on the old CMS form (08-05) will be rejected. More information can be found at unitedhealthcareonline.com.

*Information current as of March 19, 2014.
**May be delayed until October 1, 2015 with new ICD-10 postponement. Please confirm with payor.


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