Monday, December 18, 2017

OCMA Blog

OCMA Collaboration with CalOptima Secures Reimbursement Increase for ER Physicians

Emergency room physicians in Orange County will see an increase in reimbursement by CalOptima due to successful efforts by the Orange County Medical Association (OCMA).

OCMA worked in close collaboration with CalOptima to address the issue of ER physician payments. Since January 1, the full implementation of federal health reform and resulting increase in health insurance coverage has led to increased use of emergency rooms throughout the county as the system faces a growing demand for services.

Although there has been significant growth in utilization, emergency room physicians had not seen an increase in their payment rates for a number of years. This is despite the fact that Orange County ER physicians have seen a greater percentage of high-acuity cases in ERs after the implementation of health reform and the expansion of Medi-Cal and CalOptima coverage to OC residents.

ER physicians initially attempted to secure an increase from the Medi-Cal plan, but were unsuccessful. “At that point we saw that we needed help. The funding was critical to our specialty, but we realized we couldn’t get it alone, so we reached out to the OCMA,” said Dr. Peter G. Anderson, head of the ER physician team at Fountain Valley Regional Medical Center.

OCMA worked closely with executives and staff at CalOptima to develop a proposal that addressed the physicians’ needs and was financially prudent for the plan.

“We have a great relationship with the Orange County Medical Association, and work closely with them on initiatives directly impacting our physician provider partners,” stated Javier Sanchez, chief network officer for CalOptima. “The solution we put together with them on the ER rate issue is just the most recent example of that.”

The increase applies to services rendered to CalOptima patients on and after Sept. 1, 2014. The case rate was increased from $85 to $95, and physician critical care services outside of the case rate will now be reimbursed at 133% of the Medi-Cal fee schedule, up from the previous 123%.

These increases will be provided to both CalOptima Direct as well as Shared Risk Groups (SRGs) and Physician-Hospital Consortia (PHCs) working through the health networks.

The proposal was adopted by the CalOptima Board of Directors at their regular monthly meeting on Sept. 4.

“OCMA was pleased to have been able to help secure this rate increase for our ER physician members,” said Robert McCann, CEO of the Orange County Medical Association. “OCMA is proud of our advocacy on behalf of all of our physician members. We will continue to strive to do all we can to assist them in their efforts to serve the healthcare needs of the Orange County community.”

Specialty physicians received a reimbursement increase from CalOptima in December 2013, but ER physicians were exempted and did not get an increase. ER physicians are also not eligible for the reimbursement increase to primary care physicians included in federal health reform, so the recent increase was a great win for ER physicians.

Read full article in Physicians News Network - Orange County.


Blue Shield makes positive changes to reimbursement policy for physicians treating out-of-network exchange PPO patients

Blue Shield of California recently announced a two-part reimbursement policy change for contracted providers that do not currently participate in the plan's Individual and Family Plan (IFP) PPO product, otherwise known as its exchange/mirror PPO product.
 
Effective with September 14, 2014 dates of services, Blue Shield will implement changes to the out-of-network claims payment process and will now reimburse providers directly when PPO exchange/mirror product patients are seen out of network. Previously, Blue Shield issued payment directly to the patient. The notice also states that out-of-network physicians may continue bill patients for the balance of billed charges.
 
Additionally, for Blue Shield contracted providers who see Blue Shield PPO exchange/mirror patients out of network, the plan will process payment based on the provider's PPO contracted amount. Please note out-of-network benefit rules will still be applied, meaning the patient will still have the same out-of-network cost sharing. Previously, Blue Shield processed out-of-network PPO claims based on the reimbursement rate for its IFP product, which is typically discounted from the PPO rate.
 
The policy change does not affect services provided to patients with a Blue Shield IFP EPO plan, as there are no out-of-network benefits with an EPO product.
 
Blue Shield reports the policy change is in response to provider feedback of difficulties collecting from exchange/mirror patients they have seen out-of-network. The policy change also brings its physician payment rules in line with Blue Shield's facility payment policy for PPO exchange/mirror patients who are seen out of network.
 
CMA believes the policy change will be positive for physicians and commends Blue Shield for their responsiveness to provider concerns.
 
To view the Blue Shield notice, click here.
 
Physicians with questions about the policy can contact Blue Shield Provider Information & Enrollment at (800) 258-3091. OCMA members can contact Mitzi Young, OCMA Physician Advocate at (888) 236-0267 or myoung@cmanet.org

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