Monday, June 18, 2018

OCMA Blog

Resources to Assist Physicians with the Medicare Contractor Transition

Goal:   Provide members with information and resources to prepare their practices for the transition of Medicare contractors from Palmetto to Noridian on September 16 (Part B).

 

Current CMA Resources

 

1. CMA’s Medicare Transition webpage – CMA has created a dedicated Medicare transition webpage, www.cmanet.org/medicare-transition, offering practices the ability to access updates and important information regarding the transition in one easy-to-access to location. All resources related to the Medicare transition will be accessible through this site.

2. CMA’s Medicare Transition Guide: What physicians need to knowThis guide, which members can download free from the CMA website, includes an FAQ that includes information on the transition dates, what will remain the same with the transition and what will change, Noridian’s online provider portal, what practices can do to prepare for the transition, and links to additional resources and way to stay apprised of new information on the transition.

3. CMA Practice Resources (CPR)CMA Practice Resources is a free monthly newsletter from CMA’s practice management experts that focuses on critical payor and health care industry issues, including the Medicare transition, and how these issues directly impact the business of a physician practice. To sign up, visit the CMA website or contact CMA Member Services at (800) 786-4262.

4. CMA webinarAt the request of CMA, Noridian has agreed to conduct a webinar for CMA members on August 7 from 12:15-1:30pm.  The other webinars Noridian is offering is open to all provider types in California, Nevada, Hawaii, and the U.S. territories of American Samoa, Guam and the Northern Mariana Islands. However, the August 7 webinar will be limited to CMA members and will give attendees an opportunity to ask their specific questions. This webinar will be held at the OCMA Conference Center during a "Lunch & Learn." 
During the gathering, we will participate in the "live" CMA Medicare Transition webinar and then discuss any questions. To register for the Lunch & Learn, click here.


For those who miss the live webinar, it will be available on-demand via the CMA website.

 

5. Content alert updates - The CMA website allows registered users to create custom content alerts on the top­ics that are of interest to you. Once signed up, you will be notified any time there is new content posted in one of your interested areas, including Medicare issues. To sign up, users should visit their account dashboard on the CMA website and click on “my alerts,” then select “Insurance Reimbursement -> Medicare.”

 

CMA Resource in Development

 

  • Practice preparation checklist indicating all of the steps practices should take to prepare for the transition to Noridian. This document will be added to the Medicare Transition Guide.

 

MEC Engagement

 

The Priority Assistance Committee recommends that MEC proactively educate members about the resource available from CMA to help navigate contracting with the exchange.


  • Promote CMA Medicare transition website
  • Promote CMA’s Medicare transition guide
  • Promote Aug 7 Medicare transition webinar (promo from CMSS coming)
  • Include articles and announcements in CMS publications and communications
  • Alert CMA’s Michele Kelly 213/226-0338 mkelly@cmanet.org of any issues related to the transition. 

Additional Resources


  • Noridian’s transition website: The Noridian transition website includes information on what’s new/changing and what will remain the same during and after the transition.
  • Paul O’Donnell, Noridian (701) 277-2401.  NOTE: MEC are welcome to contact Mr. O’Donnell directly; however, it is important to keep CMA/Michele Kelly in the loop so that she is aware of issues as they arise.

 

Additional Medicare-related Resources

 

1.      Medicare Enrollment Guide for Physicians - This document guides  physicians through the enrollment process and assists enrolled physicians who are making changes or who must revalidate their enrollment.

2.      Getting Started with the Medicare Physician Quality Reporting System (PQRS) – this guide assists physicians with understanding and complying with PQRS.

3.      Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions – Overview of electronic prescribing (eRX) program, including incentive payments for physicians who e-prescribe and payment penalties for physicians who do not.

4.      Medicare Part B Important Changes: What they mean to your practice

5.     Medicare Audit Guide for Physicians – Guide for preparing and responding to a Medicare audit.

6.      Various Medicare webinars available on demand at www.cmanet.org/events

7.      Numerous Medicare-related CMA On-Call documents can be downloaded at www.cmanet.org


Upcoming Fundraising Event for Dr. Richard Pan, Assemblymember

Please Join the OCMA Board of Directors

for a Dinner Reception in Support of


 

DR. RICHARD PAN, ASSEMBLYMEMBER 

Friday, June 28, 2013


7:00 - 8:30 p.m.


Orange County Medical Association Conference Center

17322 Murphy Avenue
Irvine, CA 92614



$1,000 Host * $500 Co-Host $250 Supporter 

* $100 Friend * $50 Ticket


Dr. Richard Pan, a pediatrician and former UC Davis educator, currently represents the people of Sacramento and San Joaquin counties in the California State Assembly and serves as Chairman of the Assembly's Committee on Health.  He also continues to practice medicine. Dr. Pan has served in numerous capacities for his county, state, and national medical associations. He is past-President of the Sierra Sacramento Valley Medical Society and past-Chair of the CMA Council on Legislation. He is also the past-Vice-Chair of the California American Academy of Pediatrics (AAP) as well as past-Chair of the AMA Council on Medical Education and has served on the board of the Accreditation Council on Graduate Medical Education.  For a full bio, please see: http://www.asmdc.org/members/a09/biography. 



Please RSVP to Linda Johansen at: 


949-398-8100 Ext. 102 or ljohansen@ocma.org



Click here for the RSVP/Donation form



Please make checks payable to:

Dr. Richard Pan for Senate for 2014

915 L Street, Suite C415 Sacramento, CA 95814

 

You may also contribute on line at rally.org/panmd/donate

 


Department of Defense authorizes temporary waiver for TRICARE authorizations and referrals

As previously reported, since the transition of TRICARE managed care services from TriWest to United Health Military & Veterans (UMVS) on April 1, 2013, physicians are reporting significant delays in processing of authorizations and referral requests, which is affecting patient care.

The California Medical Association (CMA) recently surveyed members about the transition, and 30 percent of physicians surveyed reported significant delays in the processing of authorization and referral requests for TRICARE patients. While the standard timeframe for processing of authorization and referral requests is two business days for urgent request and five business days for routine requests, the payor has been weeks behind in processing of these requests. CMA has been working closely with UMVS to seek a resolution to this issue as soon as possible.

To address the delays, the Department of Defense (DoD) has waived authorization and referral request requirements for all TRICARE covered services April 1 through May 18, 2013. Physicians will not be required to seek or wait for an approval from UMVS for any covered services.

However, according to the UMVS Frequently Asked Questions (FAQ), if a practice received a denial from UMVS for a previously submitted request for a referral or authorization, the previous denial will remain in effect.

In a May 3 letter announcing the waiver, Lori McDougal, Chief Executive Officer of UMVS, directs physicians to provide a copy of the letter to patients at the time of referral to ensure the specialty physician knows the request is authorized.

CMA continues to work closely with UMVS to ensure the difficulties physician’s have experienced since the transition are resolved quickly.

For more information on the TRICARE transition, see CMA's TRICARE Transition Guide, available free to members in CMA's online resource library at www.cmanet.org/resource-library.

Questions about the waiver should be directed to UMVS Provider Services at (877) 988-9378.

Contact: CMA’s reimbursement helpline (888) 401-5911 or economicservices@cmanet.org.


Health Reform Heats Up

By James Noonan, CMA Staff Writer

More than three years have passed since the Affordable Care Act (ACA) was into law, setting into motion some of the most dynamic and volatile years the nation’s health care industry has ever seen.

Since its inception, the law has been a subject of controversy, inspiring hotly contested debates in Washington, D.C., Sacramento and across the entire nation. For some, this dramatic overhaul of the nation’s health care system represents our national leaders finally making good on the long-overdue promise of “health care for all.” Others claim that the law is a clear overreach of federal authority that threatens to overburden an already fragile economy.

Although the law remains controversial, the United States Supreme Court has ruled that the law is constitutional and active steps are being taken to move forward at the federal and state level.

Despite being signed into law more than three years ago, the vast majority of activity has yet to come. With many of the provisions set to take effect on January 1, 2014, state officials across the nation are scrambling to make sure they’re ready to implement the law’s sweeping changes.

The road has already been a somewhat rocky one.

Throughout the implementation process, the U.S. Department of Health and Human Services has been narrowly meeting its own deadlines, often times leaving states waiting for federal guidance that could dramatically alter their own implementation plans. With several major deadlines coming in the next few months, many observers expect this problem to only get worse.

Adding to the headache for the federal government is the fact that the ACA has received mixed support from the states, which has complicated implementation efforts nationwide. As of early February, only 19 states had elected to develop their own state-run “exchange,” an online marketplace where consumers can purchase subsidized coverage. An additional five states will form state-federal partnerships to operate their marketplaces, while the remaining states have declined to participate, meaning the federal government will be responsible for operating exchanges in those areas.

Despite these problems, the march toward reform continues on.

The Next Major Milestone

The next major milestone toward full implementation is set to take place on October 1, 2013, when state exchanges are set to begin their pre-enrollment. In the first years following these marketplaces going live, more than 32 million currently uninsured Americans are expected to gain coverage, either through an exchange plan or the ACA’s massive expansion of the Medicaid program. Some analysts expect as many as 5 million of these newly insured to come from California.

Three months after the pre-enrollment begins, January 1, 2014, exchanges are set to go live, meaning that millions of Americans will, for the first time, be able to purchase coverage using the federal subsidies promised in the ACA.

In order to navigate this massive undertaking, states will need to decide which plans will be offered through their exchanges, construct the actual online marketplaces through which consumers will purchase coverage and implement major public outreach campaigns to ensure that these citizens – many of whom have never had the benefit of “open enrollment” or a similar purchasing period – understand how and where they can sign up for coverage under the reform law.

The task is daunting on its own, but with a deadline looming only months out, skeptics would be forgiven for questioning whether such a task is even possible.

California Leads the Way

Despite the uncertainty swirling around the ACA’s implementation, California looks to be on track to meet the coming deadlines.

In the days following the ACA’s passage, California was the first state to establish a health benefit exchange (Utah and Massachusetts were operating their own versions of an exchange before the ACA was signed into law) and has been working toward implementation ever since. That exchange, recently named Covered California, has already launched its online consumer marketplace, www.coveredca.com, and is one of 25 states that have gained conditional approval from the federal government to operate its own insurance marketplace.

There is, however, still much work to be done at the state level.

Unlike most other states, California opted to adopt an “active purchaser” model when building its new exchange, meaning Covered California’s Board of Directors will be responsible for selecting which insurance providers will be allowed to offer products on the exchanges. The selected products, known as qualified health plans (QHPs), will be required to meet a set of benefit standards finalized by the Covered California board late last year. The QHPs will be selected through a competitive bidding process set to begin in the coming months, and it’s anticipated that somewhere between three to five QHPs will be selected for each one of California’s 19 geographical rating regions.

While the selection process is still far from over, it looks as though the Covered California board will not be short on options when it comes time to award the QHP designation. In October, more than 30 distinct insurance providers issued a “notice of intent to bid” to the board, and most of the state’s major insurance providers have since gone public with their intent to participate in California’s exchange.

The fact that insurance companies appear more than willing to play ball with the exchange, and that Covered California was established as an independent government entity operating outside the control of the Legislature and governor, means that the exchange’s Board of Directors has a considerable amount of power when it comes to shaping California’s post reform heath care landscape.

Protecting Physician Interests

Unfortunately several recent decisions by the exchange board have placed California’s physician community on its heels. The California Medical Association (CMA) has been an active participant in stakeholder hearings and is working to ensure that the interests of physicians and their patients are taken into consideration as the exchange prepares to open for business.

Several of issues of concern arose when the board was working to finalize the benefit standards that interested payors will be required to meet in order to have their products considered for the QHP designation. One major concern for physicians is how the exchange plans to deal with monitoring and ensuring network adequacy among of QHPs.

Throughout the benefit design conversation, exchange staff continued to favor the existing method of network monitoring, which calls for the Department of Managed Health Care (DMHC) and Department of Insurance (DOI) to be responsible for ensuring that plans offered to consumers have enough participating providers. In other words, the status quo. Several stakeholders, including CMA, have noted that those two entities are currently unable to ensure adequate networks among existing plans and would likely be overwhelmed by the added task of monitoring additional exchange products. While CMA asked that the exchange take an active role in monitoring networks beginning in 2014, the DMHC/DOI method remained in the final benefit standards adopted by Covered California’s Board of Directors in August, meaning it could become the norm once the state’s marketplace goes live.

CMA also voiced concern over the exchange’s handling of the “grace period” provision included in the ACA. Under current California law, patients who are delinquent on their premiums are allowed a full 90 days to settle up before their policy is terminated for nonpayment. However, under the ACA’s grace period provisions, exchange plans will be allowed to suspend payment for services rendered if an enrollee is more than one month delinquent. If the patient fails to settle up within the three-month grace period, the plan can then terminate coverage for nonpayment and deny all pending claims for services. In this scenario, physicians could potentially be on the hook for 60 days worth of services with no avenue for recourse.

CMA has repeatedly asked Covered California’s board to reconcile the state and federal policies, but to date an adequate fix has not been presented.

Given the exchange’s accelerated timeline, as well as the exchange board’s tendency to revisit issues that were previously thought to be decided, it remains possible that both of these matters, along with others that have caused concern to physicians, could see some sort of resolution before 2014.

Action Under the Dome

With all of the moving pieces present between the federal government and California’s exchange board, it’s sometimes easy to forget that the state Legislature is also playing a large role in ACA implementation, so large, in fact, that Gov. Jerry Brown saw fit to call for a special session dedicated to health care reform in California.

A total of six bills (three identical proposals being heard in both houses of the Legislature) were introduced during the special session, seeking to address individual market reforms (ABX1-1 and SBX1-1), Medi-Cal expansion (ABX1-2 and SBX1-3) and a proposal to establish a “bridge plan” (ABX1-2 and SBX1-3) that would allow for a seamless transition between Medi-Cal and exchange plans for those individuals whose income may fluctuate past the income thresholds called for in the ACA.

Special sessions usually are reserved for a dire situation in need of immediate legislative action, which makes it somewhat surprising that members of the Legislature allowed the spring recess – their “soft deadline” for special session legislation – to come and go without any major action on these bills. As of early April, the individual market reform and Medi-Cal expansion bills had cleared their houses of origin and were set to be heard in committees within the second house, while the bridge plan proposal had yet to be heard on the floor of either house.

There’s also a considerable amount of activity related to health reform taking place outside of the special session, specifically regarding scope of practice expansions as a way of addressing the access to care issues that will inevitably take place when millions of currently uninsured Californians gain coverage beginning in 2014. Three bills, all authored by Sen. Ed Hernandez (D-West Covina), seek to expand the respective scope of practice for pharmacists, optometrists and nurse practitioners, while a fourth, authored by Sen. Fran Pavley (D-Agoura Hills) would call for a similar expansion for physicians assistants.

The ACA had two major goals: First, to expand access to health coverage to all, and second, to ensure efficient, high quality care. Those who are now invoking the ACA as the sole justification for allowing non-physicians to diagnose and treat California patients and perform complex medical procedures are attempting to achieve the first goal by undermining the second. Allowing non-physicians to practice beyond their training can only lead to inferior outcomes, higher costs and greater fragmentation of care.

CMA will be closely following and fighting these scope bills, working to ensure that California meets the ACA's objectives without eroding quality or jeopardizing patient safety.

To be sure, the next few months will be some of the most important and tumultuous times the medical community has faced in recent memory, but as a CMA member you have the comfort of knowing that your interests are being advocated for in front of all the key players driving the nation’s reform efforts.


May Tip of the Month from OCMA Physician Advocate, Mitzi Young

May Tip:

"The Health Exchange is coming...get ready now!  With the implementation of the Patient Protection and Affordable Care Act (ACA), two thirds of California's uninsured will be covered by private insurance through a health insurance exchange purchasing pool. The exchange's goal is to start pre-enrollment in October 2013.

We have developed a toolkit to educate physicians on the exchange and ensure that they are aware of important issues related to exchange plan contracting. The toolkit is available free to OCMA /CMA members only at www.cmanet.org/exchange."

Receiving practice management guidance from Mitzi is a FREE OCMA member benefit!

Mitzi Young
Physician Advocate, Center for Economic Services
888.236.0267
myoung@cmanet.org


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