CMA signs letter of support for Medicare private contracting bill
This week the California Medical Association (CMA), the American Association of Neurological Surgeons and other physician organizations sent a letter to Congress in support of H. R....
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Physicians receiving results of Blue Cross Coding Study
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Blue Cross recently completed two follow up studies on physician coding - one on evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier -25....
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How will the increase in Medi-Cal reimbursement for primary care services work?
The Centers for Medicare and Medicaid Services (CMS) released regulations in early November implementing rate increases for primary care physicians who treat Medicaid patients....
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New Workers Compensation changes implemented in California
2-8-13
Effective January 1, 2013, new provisions of California’s workers’ compensation insurance system reform bill (SB 863) were implemented by the Department of Industrial Relations (DOI) and Division of Workers Compensation (DWC). The new provisions, approved on an interim basis, are effective for 180 days while DWC initiates formal rulemaking procedures to adopt permanent regulations....
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Did you receive a TRICARE contract from UMVS?
2-8-13
UnitedHealth Military & Veterans Services (UMVS) began soliciting physician participation in its new provider network, which will serve TRICARE beneficiaries beginning April 1, 2013. While some physicians may have received the contract notices as early as September 2012, others report they did not receive the contracts until January 2013....
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Anthem to require physicians to notify patients before referring out-of-network
In late November, Anthem Blue Cross announced that it would soon begin requiring contracted physicians to notify patients in writing before making out of network referrals. Effective March 1, the payor’s new “Advance Notice for Use of a Non-Participating Provider Policy” (APN policy) requires this notice be given using the payor-provided APN form....
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Blue Shield amending physician TriWest contracts
On December 31, Blue Shield notified physicians in the TriCare network that it is amending its TriWest contract effective February 1, 2013. While the Department of Defense awarded the TriCare West Region contract to United Healthcare effective April 1, 2013, according to the notice Blue Shield is amending its contract as it is “exploring other opportunities to continue to serve military and veteran customers....
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Medi-Cal requiring physicians to re-enroll in January
Nov. 12, 2012
The California Department of Health Care Services (DHCS) will soon be notifying physicians that they must re-enroll in Medi-Cal as one of the provisions of the Affordable Care Act (ACA)....
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Aetna reaches $120 million settlement
Dec. 11, 2012
Aetna has agreed to pay as much as $120 million to settle nationwide litigation over how it pays for out-of-network medical services....
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Physicians who wish to opt out of new Blue Cross network must act soon
Nov. 25, 2012
Over the past month, Blue Cross sent notices to physician practices advising them of the insurer’s new “Anthem Individual/Exchange Network....
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Physicians receive results of Blue Cross coding study
Nov. 2, 2012
Blue Cross recently conducted two studies of physician coding, one on new and established evaluation and management (E/M) visits, levels 4 and 5 (99204-99205 and 99214-99215), and the other on usage of modifier-25....
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Statute of Limitations on Payer Refunds
September 2012
CMA and SCCMA frequently receive calls from physicians and their staff who are approached by payers to return monies allegedly overpaid on their claims for various reasons including, but not limited to, changes in eligibility, manual processing errors or codes/services the payer considers bundled. The frequent question is whether there is a statue of limitations on how far back payers can go....
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REC partnerships double odds of EHR incentives, agency finds
Aug. 8, 2012
Providers who partner with Regional Extension Centers (REC) are twice as likely to receive Medicare electronic health record (EHR) incentive payments when compared to those who don’t, the U....
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Anthem Blue Cross announces changes to reimbursement policies and claims software
Aug. 8, 2012
This week, Anthem Blue Cross sent physicians a notice advising of upcoming changes to the insurer’s reimbursement policies and claims editing software called ClaimsXten....
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Court awards payments in UHC class action lawsuit
February 13, 2012
A federal court judge has cleared the way for nearly $200 million in awards to be disbursed to physicians through a settlement against UnitedHealth Group. This disbursement would settle claims from physicians for 15 years of artificially low payments the insurer paid for out-of-network health services....
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Blue Cross Announces Contract Changes
Posted 2-7-12
In December, Anthem Blue Cross notified its contracting physicians of impending changes to its Prudent Buyer Participating Physician Agreement, which will become effective April 1. The amendment includes an expanded confidentiality provision and several modifications to Exhibit F, which pertains to the Blue Cross Medicare Advantage PPO product....
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DMHC orders Anthem Blue Cross to stop illegal refund requests
Posted 7-24-12
The California Department of Managed Health Care (DMHC) has issued a "cease and desist" order to Anthem Blue Cross (Anthem) for violating California's unfair payment practices law....
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Blue Cross Required to Pay Providers
Posted 1-18-12
On January 12, the California Department of Managed Health Care (DMHC) ordered Anthem Blue Cross to pay health care providers money owed to them, with interest, for services provided dating back to 2007. The action is a result of Anthem’s refusal to remediate providers following a financial claims audit that identified errors in payment of medical claims....
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Blue Shield Launches Re-Contracting Initiative
Posted 1-24-12
The California Medical Association (CMA) has learned that Blue Shield is in the process of re-contracting with physicians across the state. Notices to physicians are scheduled to be mailed on January 27....
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Department of Defense awards Tricare contract
to United Healthcare
On March 16, the Department of Defense announced they had awarded a $20. 5 billion contract to United Healthcare....
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Aetna Fee Schedule changes to take effect April 1
Posted 4-3-12
CMA recently learned of changes to the Aetna Market Fee Schedule (AMFS) that will take effect April 1, 2011 for commercial lines of business in Northern California.
In a December letter, Aetna informed physicians that it would be modifying physician reimbursement rates based on the service location zip code of the rendering physician....
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UnitedHealth delays changes to prior authorization process
Posted 4-3-12
As previously reported, United Healthcare had announced they would be expanding the list of services requiring prior notification as well as begin the transition of select services from prior notification to a prior authorization requirement effective April 1, 2012.
However, CMA has learned that United has delayed implementation of the prior authorization changes in California pending approval from the California Department of Insurance....
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Cigna reduces claim filing time limit to 90 days
Posted 10-18-11
On November 1, 2011, Cigna will change the claim filing time limit for contracted providers from 180 days to 90 days. Those impacted will be notified in writing of any changes and will receive an amendment to their agreement, or will be contacted by a Cigna representative.
- When Cigna is the primary insurance, claims must be received within 90 days of the date of service.
- When Cigna is secondary, claims must be received within 90 days of receipt of the Explanation of Payment from the primary payor.
The change also applies to health care professionals whose Cigna contract includes GWH-Cigna business.
Sorting through THREE different types of “audit”
LETTERS FROM BLUE CROSS
Posted 7-25-11
Physicians are currently receiving three different audit letters from Anthem Blue Cross. This article summarizes the three audits in question and will help physicians understand the issues in play....
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Plans to Recoup Provider Payments For Medi-Cal
Posted 12-14-11
On December 2, 2011, the Department of Health Care Services (DHCS) announced it intends to recoup a 10 percent reduction in Medi-Cal provider payments retroactive to June 1, 2011, as part of the California Budget Act of 2011. The California Medical Assoication (CMA) met with DHCS immediately afer its announcement in an effort to understand how this news will impact physicians....
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Blue Cross fee schedule changes take effect Sept. 1
Posted 6-7-11
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Operating Engineers
fails to pay claims in a timely fashion
This section contains member-only content. If you do not have a username and password to log-in, contact the SCCMA office....
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Blue Cross Special Investigations Unit
CMA asks DMHC to Investigate Improper Refund Requests
7-6-11 (Sign in)
The California Medical Association (CMA) has received complaints from physicians who have received refund requests from the Anthem Blue Cross Special Investigations Unit that were outside of the 365-day period allowed by California law. As a result, CMA has filed a formal complaint with the Department of Managed Health Care (DMHC) and asked them to quickly investigate these potential violations....
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