VOLUME 1-NUMBER 2 by Merced-Mariposa County Medical Society

Merced Mariposa

Physician Volume 1 | Number 2

the physician pipeline

Promoting the science and art of medicine, the care and well-being of patients, the protection of the public health, and the betterment of the medical profession…

Merced Mariposa

Physician

MMCMS Leadership

Officers

Tahir Yaqub, M.D. President

FEDERAL UPDATE

Timothy S. Johnston, M.D. President-Elect Oscar V. Ramos, M.D. Secretary-Treasurer Eduardo T. Villarama, M.D. Immediate Past-President

Governors

Thomas A. Barrett, M.D. Gabriel Garcia-Diaz, M.D. Alfred B. Johnson, M.D. Atul T. Roy, M.D. Ajinder Singh, M.D.

9 GROWING

the physician pipeline

Glen A. Villanueva, D.O.

CMA Delegates Donald P. Carter, M.D. Pamela Roussos, D.O.

CMA Alternate Delegates Leena Chaudhury, M.D.

CASE STUDIES: Physician Empathy Can Decrease Liability Risk

Timothy S. Johnston, M.D.

Staff

Chrisy Muchow Executive Director

Contact Information 2848 Park Avenue, Suite C Merced, CA 95348 (209) 723-2976 Fax: (209) 723-8371 chrisy@mmcms.org www.mmcms.org

Merced Mariposa Physician is published quarterly by the Merced-Mariposa County Medical Society 2848 Park Avenue, Suite C | Merced, CA 95348 P (209) 723-2976 | F (209) 723-8371 E chrisy@mmcms.org | W www.mmcms.org Merced Mariposa Physician does not assume responsibility for author’s statements or opinions; opinions expressed are not necessarily those of Merced Mariposa Physician or the MercedMariposa County Medical Society. Acceptance of advertising in Merced Mariposa Physician, a publication of the Merced-Mariposa County Medical Society, in no way constitutes approval or endorsement by MMCMS of products or services advertised, and MMCMS reserves the right to reject any advertisement.

For Advertising Opportunities Contact Chrisy Muchow at (209) 723-2976 or chrisy@mmcms.org.

MORE ARTICLES, EVENTS & RESOURCES: 8

LEADERSHIP OPPORTUNITY: Associate Chief Medical Officer

EVENT: New Physician’s Reception

EVENT: Capacity Assessment Workshop

PRACTICE MANAGEMENT NEWS:  Anthem Blue Cross to reduce timely filing requirement to 90 days  Fake DEA extortion scam resurfaces in California  How to make the most of your appeals  Final MIPS scores for 2020 Medicare payments now available  CMS publishes 2017 performance data on Physician Compare website

FEDERAL UPDATE By Elizabeth McNeil, Vice President CMA Federal Government Relations

LEGISLATION SURPRISE MEDICAL BILLS CMA is fully engaged in the federal surprise medical billing legislation that would apply to all ERISA SelfInsured Employer Plans not regulated at the state level.

 CMA letter to the House Energy and Commerce

CMA is opposing legislation that mirrors the California surprise billing law. While the California law protected patients from surprise bills, it has not incented insurers to contract with physicians. Insurers across the state are refusing to renew longstanding contracts or imposing significant payment cuts which is diminishing physician networks and jeopardizing access to physicians. The California law is reducing access for patients to in-network physicians and harming access to on-call physician specialists needed in medical emergencies.

Society State of New York CEO, Phil Schuh published in Morning Consult.  CMA Statement on the Ruiz-Roe NY model legislation.

Instead, CMA is urging Congress to support a bipartisan CMA-sponsored bill, H.R. 3502 “Protecting People from Surprise Medical Bills Act,” authored by California physician Congressman Raul Ruiz, MD (D-CA) and Congressman Phil Roe, MD (R-TN). It is modeled after the proven, successful surprise billing law in New York State that has protected patients from surprise bills, incented insurers to contract with physicians resulting in more stable networks, allowed a baseball arbitration process with a payment benchmark of the 80th percentile of billed charges from the independent FAIR Health database, and has not increased costs. Premiums in New York are not rising as quickly as the rest of the nation. All of organized medicine is unified in support of the Ruiz-Roe legislation. For more information access the following documents (if you need them emailed to you contact chrisy@mmcms.org):

Committee.  Comparison of California’s law to the New York law.  Op Ed by CMA CEO, Dustin Corcoran and Medical

Recently, the U.S. Senate Health, Education, Labor, and Pensions Committee adopted on a bipartisan basis a surprise billing bill that protect patients from surprise medical bills but sets a benchmark payment rate for outof-network services provided in in-network facilities at the median in-network rate. The bill does not include arbitration, an independent databases of in-network rates, or network adequacy requirements. The CMA, AMA and all of organized medicine strongly opposed the bill. During the Committee mark-up several members expressed concerns with the bill and urged the Chairman to continue to work to find a better compromise. The surprise billing provisions were part of a much larger package of health care related bills. Since its passage, ten Senators have placed a “HOLD” on the legislation so it cannot move to the floor for a vote until a compromise can be reached. Three committees in the U.S. House of Representatives have jurisdiction over this issue. The Ways and Means Committee, the Energy and Commerce Committee and the Education and Labor Committee. The House Energy Commerce Committee’s Health Subcommittee recently (Continued on page 7)

(Continued from page 5)

adopted a surprise billing provision that mirrors the Senate HELP Committee proposal except it sets the median in-network rate at 2019 levels with an annual CPI-U inflation adjustment and it addresses accurate provider directories. CMA and all of organized medicine strongly opposed this bill as well. At least ten members of the subcommittee expressed concerns that this approach would harm physicians and seriously compromise patient access to physicians. Members of the subcommittee urged the full Committee Chairman to work with them to develop a compromise before the full committee vote. These concerned members, led by California Congressman

Raul Ruiz, are meeting with the Committee leadership over the next week to discuss alternatives. CMA leaders have been in Washington, D.C. advocating for the Ruiz-Roe bill and educating members about the unintended consequences of the California law. CMA has been in a full-court press on this legislation. Congress is on recess during the month of August and CMA will be conducting meetings with all Members of the California Congressional delegation at home in their district offices. CMA is undertaking a hard-hitting grassroots campaign to educate Members of Congress about the profound negative consequences of the Senate HELP and House Energy Commerce Committee bills. We are urging our Congressional delegation to co-sponsor the Ruiz-Roe NY model bill.

PRIOR AUTHORIZATION REFORM CMA is supporting a bipartisan bill “The Timely Access to Care for Seniors Act,” authored by California physician Congressman Ami Bera, MD that will reform the Medicare Advantage Prior Authorization system by reducing administrative hassles for physicians and patient care delays. For more information access the

following document (if you need it emailed to you contact chrisy@mmcms.org): California Medical Association supports Timely Access to Care Act

LOWERING PRESCRIPTION DRUG COSTS Congress continues to move legislation aimed at curbing prescription drug prices and drug pricing transparency. CMA is fully supportive of these efforts. However, CMA is strongly advocating that Congress

authorize Medicare to negotiate drug prices with drug manufacturers. The Veterans Administration is allowed to negotiate with the drug-makers and their prices are much less than Medicare.

PHYSICIAN SUPPLY With CMA/AMA support Congress reauthorized the Conrad 30 J-1 VISA physicain program and several committees are successfully moving legislation to

reauthorize the successful Teaching Health Center Primary Care GME program.

MEDICARE PHYSICIAN PAYMENT UPDATE AND MACRA REGULATORY RELIEF CMA continues to work with AMA to achieve a Medicare physician payment update in 2019 legislation as physicians face a five-year payment freeze. We are also

working to obtain a significant reduction in MACRArelated administrative burdens.

REGULATION ELECTRONIC HEALTH RECORD INTEROPERABILITY ENFORCEMENT REGULATIONS CMA submitted comments on the recent regulations promulgated by the Office of National Coordinator that would promote stronger enforcement of the HIT interoperability laws on vendors and hospitals. It would strengthen enforcement, increase penalties for data

blocking, reduce vendor fees and gag clauses, require real-world testing of EHRs, and modernize interoperability standards – all of which are creating practice burdens for physicians.

TRUMP ADMINISTRATION RULES TO REDUCE ELIGIBILITY FOR FEDERAL POVERTY PROGRAMS CMA joined its coalition of state medical societies in opposing recent Trump Adminitration rules to reduce

eligibility for Medicaid.

federal

poverty

programs,

including

LEADERSHIP OPPORTUNITY

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the physician pipeline By Katherine Boroski, Senior Director of Strategic Communications at the California Medical Association

robust, diverse and well-trained workforce is essential to meeting the health care demands of all Californians. While California has made great strides since the passage of the Affordable Care Act in extending health insurance to millions of residents who were previously uninsured, our state is currently facing a critical physician shortage. Californiaâ&#x20AC;&#x2122;s underserved communities are already facing a severe shortage of physicians, which will exponentially worsen as the population continues to grow, diversify and age. This will be further compounded as physicians move toward retirement faster than the replacement rate. This year, the California Medical Associationâ&#x20AC;&#x2122;s (CMA) foundation, Physicians for a Healthy California (PHC), launched two new projects that will make real progress in growing and strengthening the physician pipeline to meet the demands of Californiaâ&#x20AC;&#x2122;s growing patient population, with a focus on medically-underserved areas and populations. . >>>

GROWING the physician pipeline CalMedForce: GME Grant Program PHC’s CalMedForce program is committed to growing a diverse physician workforce by supporting, incentivizing and expanding graduate medical education (GME) in California. The program was made possible by the Proposition 56 tobacco tax, which was sponsored in 2016 by CMA, the California Hospital Association and Service International Employees Union-United Healthcare Workers West. The University of California is the designated recipient of the funding and has contracted with PHC to administer the annual grants. “These CalMedForce grants will help California grow and strengthen the physician pipeline to meet the demands of our state’s growing and changing patient population,” said Lupe Alonzo-Diaz, MPAff, PHC president and CEO. In the inaugural cycle of CalMedForce in January 2019, PHC awarded $38 million to GME programs across the state to fund approximately 150 physician residents. In total, PHC received funding requests for nearly 600 residency positions from 131 residency programs, totaling more than $147 million! The 73 programs that received awards in the first cycle represent residency positions in both urban and rural areas. Programs that focus on medically-underserved areas and populations were given priority. Of the 156 residency positions funded, 74 are existing residency slots that could have been eliminated if not for this funding. Eighty-two of the positions funded are brand new – 60 of them in new residency programs and 22 at existing programs. “The demand for these funds is a clear indicator of the statewide need for this funding and an example of how the new tobacco tax will help improve access to care in California,” said Cathryn Nation, M.D, associate vice president for health sciences in the UC Office of the President. Every dollar invested into expanding residency slots in California is significant, considering one primary care resident can conduct approximately 600 patient visits per year.

Why is GME Funding So Important? Sadly, California is a mass exporter of medical students. Every year, hundreds of graduating medical students do not find a residency slot in California to continue their training. “Inadequate funding for medical residency programs forces talented young doctors who want to stay and practice in California to train in other states,” said CMA President David H. Aizuss, M.D.

The data shows that most physicians set down roots in the areas where they train and remain there after their training to care for their communities. When Californiaeducated medical students leave to another state for a residency program, they often do not return. Overall, 54.2% of individuals who completed residency training from 2008-2017 are practicing in the state of where they trained. California ranks the highest of all states, with a 77.7% rate for in-state retention. We can grow our physician workforce by expanding the number of California residency positions.

GROWING the physician pipeline CalHealthCares: Loan Repayment Program Ample research demonstrates that the Medi-Cal system is struggling from persistent underfunding. As a result, California ranks among the lowest in the nation in payments to providers. These chronically low reimbursement rates have a direct effect on Medi-Cal patients’ ability to receive timely treatment from a physician. Compounding the problems is the fact that physicians often enter practice with hundreds of thousands of dollars in educational debt. This debt burden, coupled with low reimbursement rates, makes it unsustainable for many physician practices to take on a significant number of Medi-Cal patients. In April 2019, the California Department of Health Care Services (DHCS) launched a new loan repayment program—CalHealthCares, which incentivizes physicians to provide care to Medi-Cal beneficiaries by repaying educational debt up to $300,000 in exchange for a fiveyear service obligation. DHCS has contracted with PHC to administer the program. CalHealthCares was also made possible by Proposition 56, which provided a one-time allocation of $220 million for state loan repayment programs.

The first round of applications for the new CalHealthCares statewide loan repayment program attracted more than 1,200 applications from physicians and dentists who agreed to see more of California’s 13 million Medi-Cal patients in exchange for repayment of their student loans. In all, requests totaled more than $300 million, reflecting tremendous interest in the fiveyear program. All awardees are required to maintain a patient caseload of 30% or more Medi-Cal beneficiaries. The program is open to physicians who graduated from a residency program and/or completed a fellowship within the past five years (on or after January 1, 2014). There are no geographic limitations—providers may be located in any California county. With more than 13 million Californians relying on MediCal programs to provide basic and specialty care for serious diseases, the stakes are high. “The CalHealthCares program promises to have a real and immediate impact on access to care for Medi-Cal patients,” said Dr. Aizuss. “Especially for new enrollees, who often struggle to access to timely and quality care.” For more information about CalMedForce and CalHealthCares, visit the PHC website at phcdocs.org.

GROWING the physician pipeline PRESS RELEASE: CalHealthCares to pay $58.6M in loans for 247 physicians who commit to serve Medi-Cal patients SACRAMENTO—Physicians for a Healthy California (PHC) announced a commitment to pay off $58.6 million in student loans for 247 physicians under a new program created to expand access to care for Medi-Cal patients. Nearly 1,300 health care providers applied to the CalHealthCares loan repayment program, which pays up to $300,000 in debt relief in exchange for meeting certain criteria such as maintaining a patient caseload of at least 30% Medi-Cal patients, being in good standing with state licensing boards and other service time obligations. The awards are intended to improve access to care for low-income patients by creating economic incentives for physicians and dentists to provide care to Medi-Cal beneficiaries. “The overwhelming response we received shows that providers are eager to serve communities that need more access to care,” said PHC CEO Lupe Alonzo-Diaz. “We want to thank all of the awardees for their commitment to bring quality health care to medically underserved communities.” The awardees will be providing services to Medi-Cal patients in 39 counties throughout California. They

represent 40 specialty areas of medicine including pediatrics, psychiatry and OB/GYN. Additionally, the awardees vary in different practice settings including academic, community clinic or Federally Qualified Health Centers (FQHCs), government, group practice, hospital and private practice. A total of $340 million has been allocated to the CalHealthCares program from Proposition 56 revenue. The recent announcement of awardees is the first of at least five rounds of funding. In 2018, SB 849 established the Proposition 56 Medi-Cal Physicians and Dentists Loan Repayment Act Program and appropriated $220 million for the loan assistance program for recently graduated physicians and dentists. An additional $120 million was added to the program in Governor Newsom’s revised 2019-20 budget. The Department of Health Care Services (DHCS) administers the CalHealthCares program, with PHC contracted to manage daily activities. CalHealthCares will accept applications for its next round of awards in January 2020. For more information, visit calhealthcares.org.

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CASE STUDIES: Physician Empathy Can Decrease Liability Risk By Norcal Group

lthough physician empathy may seem to be a low priority in comparison to clinical skill, research indicates that physician empathy has wide-ranging effects for both physicians and patients, including better patient outcomes, greater patient satisfaction, less stress and burnout, and â&#x20AC;&#x201D; as the following case studies show â&#x20AC;&#x201D; it can affect whether a patient files a medical liability lawsuit. >>>

CASE ONE: LACK OF PHYSICIAN EMPATHY LEADS TO ALLEGATION OF INTENTIONAL INFLICTION OF EMOTIONAL DISTRESS You don’t have to like a patient to be empathic. In the following case, the relationship between the physician and patient was strained by a variety of non-clinical issues, including:  The gastroenterologist didn’t like obese people.  The gastroenterologist was irritated by patients who

didn’t prepare for colonoscopies.  The practice failed to schedule procedures with the

same gastroenterologist with whom the patient’s preprocedure consultation had been conducted.  The practice failed to order supplies that accommodated obese patients.  The patient was emotionally frail. Consider how this patient’s experience could have been different if the gastroenterologist had taken a moment to “stand in the patient’s shoes,” gotten a sense of the experience the patient was having in the endoscopy center and altered his behavior towards the patient.

ALLEGATION Inappropriate and disparaging comments made during a colonoscopy resulted in emotional distress.

CASE FILE A 40-year-old morbidly obese man with a family history of colon cancer presented for his first screening colonoscopy. During his deposition, the patient described his experience as follows. After waiting for a half hour in the waiting room, he was called back for a meeting with the intake nurse. When he reported that he was not able to completely consume the prescribed bowel-cleansing solution, the nurse reprimanded him and told him the procedure might need to be rescheduled. Nonetheless, she told him to change into a hospital gown, which was so small that the patient’s entire backside was exposed. When the patient was wheeled into the endoscopy suite, he was met by an unfamiliar, angry-looking gastroenterologist. The gastroenterologist did not introduce himself. When the patient asked for general anesthesia, the gastroenterologist told him he was too fat. The gastroenterologist then told the nurses to have the patient roll onto his side. However, the examination table was not wide enough for the patient to do this without difficulty. When the patient complained that he felt like he might roll off the table and asked if a bigger table was available, the gastroenterologist told him that they didn’t have any tables for patients his size and that he would have to go to the hospital if he wanted a bigger table. The patient decided he would go forward, despite the small table.

A few minutes after the scope was inserted, the patient reported sharp pains in his abdomen. The gastroenterologist told the patient to relax and continued to advance the scope. When the patient started moaning, he was told to stop complaining. The patient tried to be quiet, but he couldn’t help it and eventually cried out and tried to get up from the table. The gastroenterologist pushed him back down and loudly told him to stop moving around or the scope would put a hole in his colon. The gastroenterologist then announced the procedure was over and roughly removed the scope. He told the patient that feces were blocking his colon and he could not continue. He then left. The nurse apologized for the gastroenterologist’s behavior and explained that poor colon prep often brought out the worst in him. The patient couldn’t believe there were feces blocking his colon because he had been having watery diarrhea for the past four days. He believed the gastroenterologist must have stopped the procedure to punish him. Shortly after the procedure, the patient filed a complaint with the medical board, a grievance with his health insurer and filed a lawsuit against the gastroenterologist and endoscopy practice. The patient claimed such a degree of fear and anxiety from this experience that he could not bring himself to obtain another colonoscopy, then worried that he would die from undiagnosed colon cancer at a young age, just like his mother had.

DISCUSSION The gastroenterologist recalled he had encountered stool throughout the patient’s colon, but he had been able to advance the scope up to the splenic flexure, where he encountered solid stool that was impassable. He therefore terminated the procedure. The gastroenterologist also recalled that the patient was unpleasant to him and his staff and made a lot of noise during the procedure. He explained that the patient was not a good candidate for complete anesthesia because of his obesity and history of heart disease. He admitted to having trouble treating morbidly obese patients for both personal and medical equipment-related reasons. In retrospect, he believed that the patient should have had the colonoscopy done in the hospital, which had equipment to accommodate morbidly obese patients. Because the patient’s sole allegation was intentional infliction of emotional distress, the defense of the claim would depend in large part on how believable the patient’s story was and whether a jury would believe the patient’s testimony about abusive comments over that of the gastroenterologist. In the patient’s favor, he was in a clearly vulnerable position, not only because of the (Continued on page 17)

(Continued from page 16)

nature of a colonoscopy, but also because he was wearing a gown that did not cover his girth and was on an examination table that did not accommodate him — this would cast the gastroenterologist (who was also the owner) as insensitive towards obese patients if the matter reached a jury. Furthermore, the nurse’s alleged comment tended to show that the gastroenterologist had a history of mistreating unprepared patients. Additionally, the patient made a good impression during his deposition and the defense team felt his story could be believed by a jury. The defense team further surmised that the patient’s experience with the gastroenterologist must have been very upsetting due to the lengths the patient had gone to in order to have him held accountable. Despite this, the defense team believed this case could

be defended. The gastroenterologist also was expected to present well in front of the jury. In deposition, where he came across as believable, he denied treating the patient with disrespect, calling the patient “fat” or using any other derogatory language. However, he admitted he most likely raised the patient’s obesity as a medical issue. He adamantly denied roughly removing the colonoscope or terminating the procedure out of spite. He admitted to forcing the patient back on to the examination table to keep him from injuring himself. He also admitted he often spoke to patients in a loud voice, but that it was necessary because they were under sedation. In his opinion, the patient had misconstrued his words and actions. Shortly before trial, the gastroenterologist requested that the case be settled for a minimal amount. He did not want to go through a trial and was not comfortable with the potential of a plaintiff’s verdict.

CASE TWO: PHYSICIAN EMPATHY CAN AND DOES DECREASE LIABILITY RISK Medical liability risk appears related to patient dissatisfaction with various physician attributes associated with empathy.1 NORCAL claims specialists will tell you that good rapport with patients who later experience unexpected outcomes can have a significant effect on whether patients file lawsuits, and if they do, their willingness to dismiss or settle claims for reasonable amounts. In the following case, the surgeon’s relationship with the patient and empathic response to an unexpected outcome kept the patient from filing a lawsuit against him.

and never pointed fingers, although he believed that the patient’s injuries most likely occurred during general anesthesia induction. Due to infections and other complications, which required extensive surgeries and procedures, the patient spent two months in the hospital. The surgeon visited frequently to check on the patient’s progress, offer support and answer questions. He got to know the patient’s wife and children. When the patient was finally discharged, he had residual discomfort from the various surgeries he had endured, but he was otherwise expected to make a full recovery.

ISSUE

A 50-year-old patient was referred to a surgeon for esophageal strictures. During the pre-surgical consultation, the surgeon went through the risks, benefits and alternatives of the procedure. He specifically discussed the patient’s history of gastroesophageal reflux disease (GERD) and how it affected the risks, alternatives and benefits determination. The physician and patient determined that endoscopic surgery to stent his esophagus was the best choice.

Unfortunately, the hospitalization and recovery made it impossible for the patient to work for close to a year, which put the family under significant financial strain. The family considered filing for bankruptcy, but then it occurred to them that the surgeon (whom they believed had caused the perforation) might reimburse them for their out-of-pocket expenses and the lost income. The patient emailed the surgeon, explained their reasoning and requested a reasonable amount. The surgeon referred the matter to the NORCAL Claims Department. A defense expert reviewed the file and came to the determination that the perforation was caused by the surgeon’s negligence. The patient told the claims specialist that he had carefully considered filing a lawsuit to pursue pain and suffering damages in addition to the lost wages and out-of-pocket expenses. However, he and his family liked and respected the surgeon and did not want to involve him in a lawsuit.

During the procedure, the patient’s esophagus was perforated. When the perforation was discovered, the surgeon informed the patient and told him about the plan to repair it. He apologized without admitting guilt

The claims specialist was able to confirm the income loss and out-of-pocket expenses amounts and the matter was settled for the amount the patient requested.

Good rapport with the surgeon resulted in the patient requesting reimbursement of out-of-pocket expenses with no pain and suffering damages and no lawsuit, even though the surgeon’s negligence most likely caused the patient’s injuries.

CASE FILE

RECOMMENDATIONS: MEDICAL LIABILITY RISK MANAGEMENT RECOMMENDATIONS Being empathic with every patient does not have to be uncomfortable, difficult or time consuming. Consider the following strategies:2,3,4,5,6,7

 Sit at the patient’s level.  Apologize for patient wait time, even if it was a short

time.  Use social touch (e.g., hand shake, pat on the back),

 Try to make every patient feel like he or she is the most  



important part of your day. Stand in the patient’s shoes when considering their emotions, needs and health issues. Learn more about nonverbal communication — facial expressions, micro-expressions, body language, eye reading, tone of voice — to aid in the understanding of patient feelings. Project pleasantness and ease even when you are not feeling it.  Increase your awareness about your own nonverbal communication. Ask a staff member to observe your interactions with a few patients to gauge your empathy. Listen to how known empathic communicators (e.g., colleagues, leaders, friends, television personalities) use their voices to express empathy, and practice this for times when empathy is a struggle. Practice saying phrases in the mirror that call for empathy (e.g., “I imagine it must be difficult to...”), judge your abilities and make adjustments. Try not to be judgmental. Strive for a relationship in which you are perceived as a healer and ally, not simply a service provider. If you have trouble being empathic with a particular patient, try to figure out why and how to overcome it.

but don’t overdo it.  Use motivational interviewing techniques to come to

 



  

DURING THE PATIENT ENCOUNTER    

Knock on the door before entering the exam room. Smile when you enter the room. Greet patients using their names. Make and maintain eye contact.  If you use a computer, put the computer or patient in a position that allows you to face the patient. If that is not possible, invite the patient to join you while you type into their record.

    

an understanding of:  What is important to the patient  What the patient thinks is causing his or her health issues and how he or she thinks the issues can be addressed  What the patient is feeling about his or her health issues and why he or she is feeling that way Start the examination with an open-ended question, such as “What brings you here today?” Actively listen to the patient for at least a minute before interrupting.  It only takes a patient about 29 seconds to state a chief complaint; but physicians, on average, only give patients 18 seconds before interrupting them.8 Observe and respond to the patient’s body language and facial expressions — what the patient is saying may not sync with the patient’s non-verbal communication. Get a sense of the patient’s emotional state and priorities before analyzing problems. Acknowledge and validate the patient’s emotions and concerns. Reflect back the patient’s perceived symptoms, medical history, feelings, values, ideas and concerns with open-ended phrases.  Invite the patient to correct your understanding of what has been reported, and then incorporate the correction into a new short summary. Avoid using medical jargon. Try to become interested in the patient’s story. Try to imagine the patient’s situation. Offer support and partnership. Learn how to recognize times when empathy may be counterproductive, for example, when patients indicate they don’t want to share how they are feeling.

REFERENCES 1. Hickson GB, et al. “Patient Complaints and Malpractice Risk.” JAMA. 2002; 287 (22):2951-7. (accessed 9/24/2018) 2. Hardee JT, Platt FW. “Exploring and Overcoming Barriers to Clinical Empathic Communication.” Journal of Communication in Healthcare. 2010; 3(1):17-23. (accessed 9/24/2018) 3. Bernard R. “How To Be a Rock Star Doctor.” 2015 (resource not available online) 4. Hardee J. “An Overview of Empathy.” The Permanente Journal. Fall 2003:7(4):51-54. (accessed 9/24/2018)

5. American Osteopathic Association. “Empathy in Medicine.” (accessed 9/24/2018) 6. Montague E, et al. “Nonverbal Interpersonal Interactions in Clinical Encounters and Patient Perceptions of Empathy.” J Participat Med. 2013; 5:e33. (accessed 9/24/2018) 7. Lussier M, Richard C. “Reflecting Back: Empathic Process.” Canadian Family Physician. 2007;53(5): 827-828. (accessed 9/24/2018) 8. Beckman HB, Frankel RM. “The Effect of Physician Behavior on the Collection of Data.” Ann Intern Med. 1984;101(5):692–696. (accessed 9/24/2018)

The NORCAL Group of companies provide medical professional liability insurance, risk management solutions and provider wellness resources to physicians, healthcare extenders, medical groups, hospitals, community clinics, and allied healthcare facilities throughout the country. They share an A.M. Best “A” (Excellent) rating for their financial strength and stability. Website: http://norcal-group.com | Phone: 844.4NORCAL | Email: customerservice@norcal-group.com

PRACTICE MANAGEMENT NEWS August 2019

Anthem Blue Cross to reduce timely filing requirement to 90 days Anthem Blue Cross has notified physicians (https:// www.cmadocs.org/Portals/CMA/files/public/Anthem% 20Timely%20Filing%207-2-19.pdf) that it is amending sections of its Prudent Buyer Plan Participating Physician Agreement, significantly reducing the timely filing requirement for commercial and Medicare Advantage claims to 90 days from the date of service. Currently, Anthem requires physicians to submit all professional claims for commercial and Medicare Advantage plans within 365 days of the date of service. Under the new requirement, all claims submitted on or after October 1, 2019, will be subject to the new 90 day filing requirement. However, as an example, the notice indicates that the change will impact claims with July dates of service if not submitted within 90 days. While the change in Anthem’s claim submission timeframe meets the minimum timeframe allowed by law for contracting physicians, the California Medical Association (CMA) has received several calls from physicians concerned that the June 21 letter of the material contract change was not sufficient advance notice, given the policy change impacts claims with July dates of service. As a result of CMA sponsored unfair payment practices law and the resulting regulations, plans are required to provide a minimum of 45 days prior written notice before instituting any changes or amendments about claim submission requirements.

CMA raised this concern with Anthem, but the payor believes it provided sufficient advance notice. CMA is assessing the issue to determine potential next steps. Remember, even if a physician fails to submit a claim on time, California law provides a “good cause” exception that requires payors to accept and adjudicate a claim if the physician demonstrates, upon appeal, “good cause” for the delay. Anthem has clarified that the change does not affect non-contracting physicians. As a reminder, California law states plans must allow a minimum of 180 days from the date of service for receipt of a claim for noncontracted providers. Physicians with questions are encouraged to contact Anthem Network Relations at CaContractSupport@anthem.com. For a summary of California's unfair payment practices law, see "Know Your Rights: Identify and Report Unfair Payment Practices" (https://www.cmadocs.org/ LinkClick.aspx?fileticket=basMA18Poog% 3d&portalid=53). More information on timeframes for claim submission can be found in “Know Your Rights: Timely Filing Limitations” (https://www.cmadocs.org/ LinkClick.aspx?fileticket=PnNvKcjGj7Y%3d&portalid=53) or in CMA health law library document #7511, “Payment Denials by Managed Care Plans and IPAs” (https:// www.cmadocs.org/store/info/productcd/7511/t/paymentdenials-by-managed-care-plans-and-ipas) available free to members on CMA’s Reimbursement Assistance page.

August 2019

Fake DEA extortion scam resurfaces in California Scam artists posing as U.S. Drug Enforcement Administration (DEA) agents are calling California physicians and consumers as part of an international extortion scheme. While the scam is not new—it’s been making the rounds for the past five years—a number of California physicians have reported recent extortion attempts. The scammers identify themselves as DEA agents or other law enforcement, telling their victims that purchasing drugs via phone or internet is illegal and that enforcement action will be taken against them if they don’t pay a fine, usually thousands of dollars. No DEA agent will ever contact physicians or members of the public by telephone to demand money or any

other form of payment. If you receive a call such as the one described, refuse the demand for payment and immediately report the threat using the DEA’s online form (https://apps2.deadiversion.usdoj.gov/esor/spring/ main?execution=e1s1). Please include all fields, including, most importantly, a call-back number so that a DEA investigator can contact you for additional information. Online reporting will greatly assist the DEA in investigating and stopping this criminal activity. For more information go to https:// www.deadiversion.usdoj.gov/pubs/pressreleases/ extortion_scam.htm.

PRACTICE MANAGEMENT NEWS July 2019

How to make the most of your appeals Under California’s unfair payment practices law (https:// www.cmadocs.org/LinkClick.aspx? fileticket=basMA18Poog%3d&portalid=53), payors are required to establish a fast, fair and cost-effective dispute resolution mechanism (i.e., “appeal process”) to resolve provider disputes. Anytime a payor contests, adjusts or denies a claim, they are required to advise the physician of the availability of the appeal process and instructions for submitting the appeal. Payors are also required to acknowledge receipt of a written appeal within two working days for electronic appeals or 15 working days for paper appeals. The payor is required to respond to written appeals submitted by providers within 45 working days of receipt, and they must report to the Department of Managed Health Care, on an annual basis, the nature and volume of appeals received.

directors, provider relations, appeals and other key contacts. 

Clearly state your “ask,” ideally at the beginning and the end of your letter. For example, are you asking that the bundling edits be re-reviewed, are you asking for a medical necessity appeal to be reviewed by a physician of same or like specialty, or are you disputing the payor’s claim that the patient wasn’t eligible? Simply venting about your frustration with how a claim was denied incorrectly or underpaid isn’t enough to communicate why you believe the claim was processed incorrectly or what action you are requesting in your appeal.

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Look out for the written acknowledgement of receipt of your appeal from the payor within 15 working days of the day you would expect the payor to have received it. Remember that sending your appeal certified mail will help confirm receipt of your appeal by the payor. If you don’t receive the acknowledgement of receipt, there is likely a problem and a phone call to the payor may be in order.

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Look out for the payor’s written response to your appeal that should include the pertinent facts and reasons for its determination, which should arrive within 45 working days of receipt of the appeal.

The California Medical Association (CMA) recommends the following to ensure your appeal is addressed properly by the payor: 

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Clearly state in the subject line and first sentence of your letter that this is an “appeal.” Steer clear of the word “inquiry” in your appeal. Use of the word “appeal” leaves no doubt about your intention—to appeal the payment (or non-payment) of the claim— and will ensure the appeal gets to the right department and will be responded to in writing within the required timeframes. Make sure you are sending your written appeal to the correct address. Some payors, such as Blue Shield, have a different P.O. Box for claims vs. appeals. If you send your written appeal to the claims address, it will likely be processed as an “inquiry” and not an appeal, which means you may not receive a written response, let alone the desired outcome of reprocessing of your claim. If you are unsure of the appeals address, CMA’s Center for Economic Services publishes updated profiles (https://www.cmadocs.org/practice-management) on each of the major payors in California including Aetna, Anthem Blue Cross, Blue Shield of California, CIGNA, Health Net, UnitedHealthcare, Medicare/ Noridian and Medi-Cal. Each profile includes key information on health plan market penetration; a description of the plan’s dispute resolution process; and the name and contact numbers for medical

For more information regarding provider appeals, see:  CMA’s "Know Your Rights: Quick Guide for Appeals" (https://www.cmadocs.org/LinkClick.aspx? fileticket=M5QhLvVuMaE%3d&portalid=53);  “Know Your Rights: Timeframes to Appeal” (https:// www.cmadocs.org/LinkClick.aspx? fileticket=1pwH6yJExJg%3d&portalid=53) and;  CMA health law library document #7057, "Managed Care Contractual Protections" (https:// www.cmadocs.org/store/info/PRODUCTCD/7057/t/ managed-care-contractual-protections). These documents are all available free to members. Don’t forget that CMA members and their staff can also contact CMA’s practice management experts at (888) 401-5911 or economicservices@cmadocs.org if you don’t receive the acknowledgement or written response from the payor, or if you feel the dispute process has failed. We are here to help!

THE ARTICLES IN THIS SECTION ARE REPRINTED FROM CMA’S PRACTICE RESOURCES (CPR) NEWSLETTER (https:// www.cmadocs.org/cpr) AND/OR CMA’S NEWSWIRE (https://www.cmadocs.org/newsroom). FOR INFORMATION ABOUT SUBSCRIBING TO CPR OR NEWSWIRE GO TO https://www.cmadocs.org/news/subscribe.

PRACTICE MANAGEMENT NEWS July 2019

Final MIPS scores for 2020 Medicare payments now available If you participated in the Medicare Merit-Based Incentive Payment System (MIPS) in 2018, your MIPS final score and performance feedback are available now on the Quality Payment Program (QPP) website (https:// qpp.cms.gov/). The payment adjustment you will receive in 2020 is based on this final score. A positive, negative or neutral payment adjustment will be applied to the Medicare paid amount for covered professional services furnished under the Medicare physician fee schedule in 2020. Physicians, physician groups and accountable care organizations (and their authorized representatives) can access their performance feedback by logging into https://qpp.cms.gov/ with the same EIDM credentials used to submit and view their data during the submission period.

If you believe an error was made in the calculation of your 2020 MIPS payment adjustment, you can request a targeted review from the Centers for Medicare and Medicaid Services (CMS) via your EIDM account on the QPP website. Targeted reviews can be submitted until September 30. 2019. For more information about how to request a targeted review, please refer to the:  2018 Targeted Review Fact Sheet (file:///C:/Users/ Chrisy/Downloads/2018%20Targeted%20Review% 20Fact%20Sheet.pdf) and the;  2018 Targeted Review FAQs (file:///C:/Users/Chrisy/ Downloads/2018%20Targeted%20Review% 20FAQs.pdf).

August 2019

CMS publishes 2017 performance data on Physician Compare website The Centers for Medicare and Medicaid Services (CMS) recently published 2017 performance information from the Medicare Quality Payment Program (QPP) on the “Physician Compare” website: https://www.medicare.gov/physiciancompare/. The Affordable Care Act required CMS to create a website that would allow consumers to search for and compare physicians and other health care professionals who provide Medicare services. That site—the "Physician Compare" website, initially launched in 2010—provides contact information, specialties and clinical training, hospital affiliations, and group practice information. The 2017 QPP performance information on Physician Compare profile pages for Merit-based Incentive Payment System (MIPS) eligible clinicians and groups includes:

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12 MIPS quality measures reported by groups and displayed as measure-level star ratings on group profile pages 8 Consumer Assessment for Healthcare Provider and Systems for MIPS summary survey measures displayed as top-box percent performance scores on group profile pages 6 Qualified Clinical Data Registry (QCDR) quality measures reported by groups and displayed as percent performance scores on group profile pages 11 QCDR quality measures reported by individual clinicians and displayed as percent performance scores on individual clinician profile pages

For more information, see the Physician Compare Initiative website (https://www.cms.gov/Medicare/QualityInitiatives-Patient-Assessment-Instruments/physiciancompare-initiative/index.html). Physicians with questions can email PhysicianCompare@Westat.com.

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