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Winter 2012

The Bulletin

Inside this Issue: FEATURE: Inside CMA’s Center for Economic Services…(See page 7) 15th Annual California Health Care Leadership Academy…(See page 6) 38th Annual Legislative Leadership Conference…(See page 10) Call Your Member of Congress Now!…(See page 17) CODING AND MEDICARE UPDATE 2012 AND TRANSITIONING TO ICD-10-CM…(See page 20) Join us for our February General Membership Meeting…(See page 21) CES Resources Available to Physician Members…(See page 25)

Our Mission The mission of MMCMS is to promote 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; to cooperate with organizations of like purposes; and to unite with similar societies in the State of California as component societies of the California Medical Association.

MMCMS Leadership Officers Nirmal Aujla, M.D. President Samuel B. Tacke, M.D. President-Elect

CONTENTS MMCMS President’s Message—Nirmal Aujla, M.D. Appreciation and words of encouragement.....................................................5

Inside CMA’s Center for Economic Services.................................................7 The Bar on the Corporate Practice of Medicine ....................................... 11

Donald P Carter, M.D. Secretary-Treasurer

DocBookMD Case Study .................................................................................. 13

David Simenson, M.D. Immediate Past-President

News from the California Medical Association ........................................ 15

Governors E. Kip Hensley, M.D. Timothy A. Livermore, M.D. Atul T. Roy, M.D. Thavalinh Mark Sphabmixay, M.D. Mark W. Via, M.D. Eduardo T. Villarama, M.D.

CMA Delegates James H. Jones, M.D. Pamela Roussos, D.O.

CMA Alternate Delegates Stephen F. Corcoran, M.D. Eduardo T. Villarama, M.D.

Staff Chrisy Muchow Executive Director

Top News Blue Cross required to pay health care providers money owed to them, dating back to 2007 ............................................... 15 Medi-Cal News Obama Administration rejects state’s request to impose mandatory Medi-Cal co-pays ....................................................... 15 Judge blocks a 10 percent reduction in Medi-Cal reimbursement rate ..................................................................... 16 Medicare News Bipartisan support is growing for funding Medicare SGR repeal with unspent war funds........................................... 16 Medical-Legal Library Gaining market share of newly insured patients under health reform: A guide for solo and small practices............................... 17

GROUP Level Term Life Program.................................................................. 19 Meeting Schedule .............................................................................................. 21 High-Risk Issues Associated with Lawsuits— and What to do About Them .......................................................................... 23

Contact Information 2848 Park Avenue, Suite C Merced, CA 95348 (209) 723-2976 Fax: (209) 723-8371 For Advertising Opportunities Contact Chrisy Muchow at (209) 723-2976 or The Bulletin is published quarterly by the Merced-Mariposa County Medical Society, 2848 Park Avenue, Suite C Merced, CA 95348. Phone (209) 723-2976; Fax (209) 723-8371; E-mail; Website The Bulletin does not assume responsibility for author’s statements or opinions; opinions expressed are not necessarily those of The Bulletin or the Merced-Mariposa County Medical Society. Acceptance of advertising in The Bulletin 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.

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Winter 2012

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President’s Message— Nirmal Aujla, M.D. Appreciation and words of encouragement... Dear Colleagues, I would like to thank outgoing President, Dr. David Simenson for his service to MMCMS over the last two years. MMCMS appreciates his leadership and his commitment to his fellow physicians. I would also like to say thank you for your support in electing me as President for 2012. In December we partnered with CalHIPSO to hold an EHR and Meaningful Use workshop at our MMCMS office (CalHIPSO is the entity that has received the federal grant money to help physicians implement EHR in their offices). A number of local physicians signed up with CalHIPSO as a result of this workshop. Also, in December, we held our annual Holiday Reception. All physicians of the community were invited to the event held at De Angelo’s Restaurant. It was an enjoyable evening with colleagues, friends, food and fun. We have a number of events coming soon. The first of which is our February General Membership meeting with Dr. Paul Phinney, CMA President-Elect as our guest speaker. We are also having an event for office managers, administrators and billing staff in February that will offer them the opportunity to hear, “Transitioning to ICD-10-CM” and “Coding and Medicare Update 2012.” Please send your staff to these worthwhile workshops. Other events coming soon include, CMA’s Annual Legislative Leadership Day in Sacramento and our annual NORCAL CME Event here in Merced in May.

You should be receiving your Membership Directory update letters in the mail soon and we ask that you return them even if you have no changes. Also, you are welcome to have your photo updated for free, so please take advantage of that if your photo is more than a few years old. Details will be included with your letter. We have also been busy meeting with new physicians in the community and asking them to join all of you in supporting organized medicine. If you know of any physicians who are not currently members of the Medical Society please encourage them to join. Also, please feel free to contact Chrisy Muchow, our Executive Director at MMCMS if you know of anyone she should contact regarding membership. MMCMS has spent the last few years expanding the services we offer to our members and trying to make our events more relevant. We will continue to do our best to offer more services and better events and look forward to serving you in 2012. If you have any suggestions for improving what we do here at MMCMS, please don’t hesitate to contact me or Chrisy. I encourage participation by all members. MMCMS can provide us more than we might be aware of! Again, thank you for your support. Nirmal Aujla, M.D. President

Winter 2012

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Inside CMA’s Center for Economic Services


n a perfect world, the relationship between payor and physician would be a simple one.

Physicians’ claims, on-time and absent even the simplest coding error, would trickle out to payors, while reimbursement would flow back in without issue. Each side would have a full understanding of the other’s needs, and confusion would almost never arise.

More than just a staff at your average help-line, however, the team of practice management experts at CES is committed to getting results, and has been doing so in impressive fashion. Two years ago, the CES staff posted a then-record-breaking year in which they recouped more than $2.7 million from payors on behalf of their members.

Unfortunately, as any physician can tell you, the world is far from a perfect place.

In 2011, they topped that figure, with the latest count totaling over $2.8 million. The figure may grow larger as the year rolls on, as several cases open in 2011 are still awaiting final resolution.

Instead, today’s reimbursement process forces providers to navigate complex coding systems, evolving electronic health record requirements and a myriad of other complications that go hand-in-hand with practicing modern medicine.

For the more than 1,300 different practices that called upon CES’ services last year, knowing that a team of qualified advocates is willing to act on their behalf provides a welcome sense of security.

As a result, even the most efficient practice may have to deal with a denial rate of somewhere around 15 to 20 percent, according to some estimates.

“Our goal is to take the noise out of the system so that the physician can actually go back to practicing medicine,” said Jodi Black, Senior Director with CES who has spent the last seven years serving as an advocate for California physicians.

Luckily, somewhere in this world of confusion, thousands of physicians across the state have found a place to turn for help. Since 1999, the California Medical Association’s Center for Economic Services (CES) has been offering one-on-one assistance for member physicians struggling with reimbursement issues. Boasting more than 125 years of combined medical practice operations, the team at CES fields calls from practices across California, handling everything from individual payment questions to more widespread problems that can lead to hundreds – or in some cases thousands – of claims being denied.

Black, along with her colleagues Frank Navarro, Mark Lane, Michele Kelly, Kris Marck and Jennifer Williams, make up the team at CES, and are responsible for delivering one of the most immediate and tangible benefits offered by CMA. For an organization that counts more than 35,000 California physicians as members – and embarks on dozens of legislative and legal campaigns in a given year – a service that caters to the needs of individual members can be an invaluable one. (See CES, Page 8)

In 2011, CES recouped over $2.8 million from payors on behalf of members!

Winter 2012

CES (Continued from page 7)

“I think the ‘human’ aspect of it is important,” said Marck, who spent more than two decades providing contracting services for health plans before joining CMA. “Getting to speak with someone who understands can make a big difference.” In a business with complex contracts and rapidly changing regulations, this sense of “understanding” can be hard to come by.

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Navigating a challenging transition Perhaps the largest of these so-called “trend” cases to hit CES in recent memory came back in 2008, when Palmetto GBA took over for the National Health Information Center (NHIC) as the state’s Medicare claims processor. The switch came as part of a national effort to help increase efficiency in the processing of Medicare claims. For participating physicians, the results were anything but.

“The business of medicine is really changing every day,” said Navarro, a 13-year veteran of CES who has more than 35 years of practice management experience under his belt.

Differences between Palmetto and NHIC’s operations meant that a sharp learning curve was tied to the statewide switch. This, as well as a host of logistical problems that arose during the transition, resulted in a nightmare for California physicians, Navarro said.

A majority of these changes, he adds, are purely economical, designed to limit the payment amounts that plans are obligated to pay out to providers.

Across the state, thousands of practices were reporting payment stoppages on Medicare claims, causing cash-flow problems that had many physicians bracing for the worst.

“Keeping up with all of this is difficult for a lot of small and solo practices,” Navarro said, adding that CES staff are included on regular mailing lists and spend countless hours thumbing through medical publications to stay on top of the latest revisions.

Luckily, by working with both payor and provider, CES was able to help physician members navigate a transition that seemed insurmountable at first glance.

“Even for us, it’s difficult to keep up with all these changes,” he said. “Can you imagine being in a practice where you only have three staff? For those offices, we really are a lifeline.” In order to serve as that lifeline, however, the team often faces the challenge of figuring out where things went wrong in the first place. Lane, who spent roughly 16 years processing claims and conducting provider relations for two large insurance plans before joining CES, was able to explain the reimbursement assistance process in the simplest of terms. “It’s kind of like finding that one needle in the haystack, and then doing everything you can to get it fixed,” he said. With causes for denials ranging from illegible or missing signatures to a lack of timely filing or incorrect procedure code, getting to the root of the problem can often require a fair amount of detective work, Lane said. Marck agreed, noting that it can be “easy to give an easy answer, but difficult to find the right answer.” “Sometimes we can make a phone call and get it fixed,” Black adds. “Other times we can’t. It’s just not that simple.” In some instances, these less than “simple” cases wind up being tied to a larger trend, meaning one or two calls for help can soon snowball into dozens of different practices looking for answers on the same issue. “We only know what’s going on out there when practices call and tell us,” Black said. Navarro agreed, noting that having physicians report problems was “hugely important” to CES’ efforts, because, as he put it, “if it’s happening to one, it’s happening to many.”

“We literally helped thousands of practices get paid,” Navarro said, noting that CES’ assistance to one large-group practice resulted in claims totaling roughly $11 million being fully processed. CES staffer Michele Kelly, who had spent nearly four decades with Transamerica and NHIC, the contractors previously responsible for administering the Medicare program, before joining CMA in 2008, noted that issues stemming from the switch dominated the center’s call volume during that transition period. “It was difficult, particularly for the small and solo practices,” she said. An emphasis on education In the complex world of insurance reimbursement, however, not every denied claim is the result of a newly written rule or statewide service change. In some cases, an error or misunderstanding on behalf of the provider could just as easily be the cause. “It’s not always the plan’s fault,” Black said. In order to help cut back on such occurrences, a large part of CES’ mission is to “educate physicians and their staff” on how to improve the efficiency of their practice, she added. Evidence of this portion of the Center’s mission can be found on CMA’s recently revamped website, where CES has carved out its own mini practice management resource library that features on-line tool kits, contract analyses for all of state’s the major plans and a special ‘know your rights” section designed to help empower physicians. Once a month, the staff at CES boils down the latest in practice management news for “CMA Practice Resources” (CPR), a regular publication distributed to more than 1,000 California physicians. (See CES, Page 9)

Winter 2012

Page 9


Need assistance?

(Continued from page 8)

“A lot of what we do is education,” said Kelly, who operates out of CMA’s southern California office and frequently addresses county medical societies on topics relating to Medicare. While their mission may vary from day to day, each member of the CES team noted that one thing remains constant throughout the phone calls, presentations and countless hours of research.

Members can contact CMA’s reimbursement help line at (888) 401-5911 or Visit CMA’s Center for Economic Services online at Subscribe to CMA’s Practice Resources at

“The gratitude is just amazing,” Navarro said. “There isn’t a day that goes by that I don’t hear ‘thank you.’” Though much of the advice and education offered of the CES might be complicated and nuanced by nature, it’s the most frequent tip delivered by the team that ends up being the simplest – “If you need help, call us.” “Don’t hesitate,” Marck said. “I mean, why not?”

For a complete listing of CES Resources Available to Physician Members see pages 25-27! PROVIDING PROFESSIONAL RADIOLOGY SERVICES TO Mercy Medical Center • John C. Fremont Hospital Castle Family Health Centers • Patient’s First Medical Center and other Health Care Providers in the Greater Merced Area

P.O. Box 3649 • Merced, CA 95344 209-722-9729 (722-XRAY) • Fax: 209-384-9729

Winter 2012

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The Bar on the Corporate Practice of Medicine CMA Center for Legal Affairs

What is the bar on the corporate practice of medicine? The bar on the corporate practice of medicine prohibits lay individuals, organizations and corporations from hiring or employing physicians, or from otherwise interfering with a physician’s practice of medicine. The bar also prohibits lay entities from engaging in the business of providing health care services by contracting with health care professionals to provide those services. The corporate practice bar does not apply to physician partnerships or professional medical corporations because they are controlled by physicians (Business and Professions Codes §2052 and 2400).

Can hospitals employ physicians? The California Attorney General has concluded that hospitals may not employ physicians to provide professional services. For example, to the extent a pathologist practices medicine (i.e., prescribes, diagnoses, etc.) as a hospital laboratory director, the nonprofessional corporate laboratory that employs the pathologist is unlawfully engaged in the practice of medicine. To prevent violating the bar, doctors who work in hospitals form physician groups that enter into contracting agreements with hospitals. The medical group is responsible for paying the physicians’ salaries, not the hospital. Conversely, the medical staff at the hospital is responsible for granting practice privileges and for oversight of physicians. Physicians can enter into contracts to provide services at a hospital, but the ability for physicians to share revenue with a hospital is also limited. Revenue sharing can only be done as long as a physician's independent contract with a hospital does not impair the physician's freedom of action, and the compensation received by the hospital is commensurate with its expenses incurred in connection with furnishing the facilities and services rendered. If the payments to the hospital exceed the actual value of services rendered, this would be considered fee splitting and is illegal.

Are there exceptions to the corporate bar? Yes, under limited circumstances, certain types of hospitals may directly employ a physician, including: Teaching hospitals: Business & Professions Code §2401 allows a clinic operated primarily for the purpose of medical education by a private or public nonprofit university medical school to charge for professional services for “teaching patients” rendered by physicians who hold academic appointments on the faculty. As long as the facility is used primarily for the purpose of medical education and the services are for "teaching patients," employment is authorized.

Hospital districts: The California Legislature created an exemption for hospital districts to employ physicians under extremely narrow circumstances. County hospitals: The laws prohibiting the corporate practice of medicine do not apply to counties given the broad "police powers" granted to them by the state. Thus, counties may employ physicians.

Are there other ways to legally circumvent the bar? No. Lay entities have attempted to circumvent the corporate bar by engaging physicians in various types of business arrangements, but these strategies are illegal. For example, a lay entity/hospital might agree to handle all business decisions and employ a physician to handle all clinical decisions. However, it is difficult if not impossible to isolate business decisions from those affecting the quality of care delivered to patients. The purchase of a piece of radiological equipment, for instance, could be looked at as a purely business consideration or as a medical decision or as an amalgam of both. In addition to prohibiting lay entities from taking outright control over traditional medical decisions, California law prohibits most lay entities from, among other things:  Having an economic interest in the net profits of a medical

practice, and/or  Contracting with physicians on an employment or independent

contract basis for the provision of medical services. If a lay entity has a financial interest in a physician's "bottom line," then the entity has a direct interest in and ability to control the medical side of the business, such as how many hours the physician will work, what medications the physician may purchase, and what type of medical technology should be utilized. This is illegal. Extreme caution should be taken if a hospital is trying to integrate medical practices through a “friendly” physician who has a majority stock in a medical corporation. An affiliated professional corporation can be used by hospitals to circumvent the bar. The courts and the Attorney General's office can and do find such arrangements in violation of the bar where it appears that the lay entity is controlling the practice of medicine. For more information, see CMA medical-legal document #0280, “Corporate Practice of Medicine Bar.” _______________________________________________________ This article is adapted from CMA medical-legal library document #0280, “Corporate Practice of Medicine Bar,” available at

Winter 2012

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Winter 2012

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News from the California Medical Association Top News Blue Cross required to pay health care providers money owed to them, dating back to 2007 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. California Medical Association (CMA) President James T. Hay, M.D., applauded DMHC for their recent announcement. “We provide necessary care to our patients based on the assumption that the health plans will promptly and accurately reimburse us for services rendered,” Dr. Hay said. “Anthem Blue Cross’s refusal to pay for a mistake on their end puts an undue burden on those of us who provide care.” In 2008, DMHC launched provider claims audits of the seven largest health plans in California due to a growing pattern of complaints from providers regarding late and inaccurate payments and inappropriate claim denials. These audits found claims payment violations above the threshold allowed under California law at all seven health plans. In response to the audits, DMHC required the plans to pay providers the money they were owed and to demonstrate improvements to the plans’ claims processes to prevent future errors. In addition, each plan entered into settlement agreements to pay administrative fines. To date, six of the seven plans have undertaken provider remediation efforts.

Anthem has refused to pay providers for the claims violations uncovered in the audit. Now, Anthem Blue Cross has 30 days to submit to DMHC a corrective action plan to identify the claims that were not correctly paid and pay the providers as prescribed by law. Center for Economic Services helps physicians recoup money denied by payors CMA’s Center for Economic Services (CES) provides one-on-one assistance to physician members and their staff for reimbursement and practice operations issues. For the second year in a row, CES has recouped more than $2.7 million from payors on behalf of its members. The center’s reimbursement help line has fielded over 2,600 calls about billing and contracting issues from more than 1,200 different physician practices. “The work that the Center for Economic Services does at CMA is phenomenal for physicians who are facing difficulties with payors, but they can only do so much. The decision by DMHC to move forward and require Anthem to pay health care providers what they are owed is a huge relief, especially when Medicare and Medi-Cal programs are being cut,” Dr. Hay added. For a full copy of the DMHC press release, please visit their website. Contact: CMA reimbursement helpline, (888) 401-5911 or

Medi-Cal News Obama Administration rejects state's request to impose mandatory Medi-Cal co-pays On February 6, 2012, the Centers for Medicare & Medicaid Services (CMS) rejected California’s request to impose mandatory co-payments for Medi-Cal patients. This attempt by the state to save $511 million in last year’s state budget by slashing Medi-Cal costs featured a $5 copay for physician office and clinic visits, a $50 copay for emergency room (ER) visits and a $100 copay per day for inpatient hospital stays (up to a $200 maximum). “The Obama Administration has made the right decision. By federal law and our own ethics, physicians must treat patients who come to the ER, regardless of ability to pay. Imposing a mandatory co-payment would have done nothing to address costs or improve patient care. We are pleased that CMS understands that and has rejected the proposal,” said James T. Hay, M.D., California Medical Association (CMA) President.

The proposed copayments exceeded the limits allowed by federal law for Medicaid cost sharing. “These co-payments would for all intents and purposes be uncollectable, and would have made it even harder for Medi-Cal patients to gain access to the care and medication they need,” Dr. Hay added. “Copayments discourage low-income families from filling prescriptions because they can’t afford it. When patients fail to take their prescription medications correctly, or stop taking their medications altogether, this seriously undermines their quality of life, quality of care, health care outcomes and the value of health care dollars spent.” The rejection comes just days after Federal Judge Christina Snyder issued her final ruling in CMA et al. v. Douglas.

(See News, Page 16)

Winter 2012

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News (Continued from page 15)

Judge blocks a 10 percent reduction in Medi-Cal reimbursement rate On Tuesday, February 1, 2012, U.S. District Court Judge Christina Snyder issued a final order enjoining the State of California from implementing a 10 percent cut to the Medi-Cal reimbursement rate. Last spring, the California Legislature passed and Governor Jerry Brown signed Assembly Bill 97, which authorized up to a 10 percent Medi- Cal reimbursement rate cut for physicians, hospitals, dentists, pharmacists and other Medi-Cal providers. Federal approval was required before the state could implement its proposed cuts. The Centers for Medicare & Medicaid Services (CMS) approved the state plan amendment in December 2011. The California Medical Association (CMA), California Dental Association, California Pharmacists Association, National Association of Chain Drug Stores, California Association of Medical Product Suppliers, AIDS Healthcare Foundation and American Medical Response filed the lawsuit against the U.S. Department of Health and Human Services and the California Department of Health Care Services in November 2011, with financial support from the California Academy of Family Physicians and the Osteopathic Physicians & Surgeons of California. The organizations argued that if the cuts went through, access to care for Medi-Cal patients would be eroded or cut off completely.

“This is tremendous news for the future of medicine,” said James T. Hay, M.D., CMA President. “Judge Snyder’s prompt issuance of today’s ruling is evidence of the important nature of this case. The state’s repeated attempts to slash Medi-Cal reimbursements have been halted, once again. Rather than focusing on Medi-Cal cuts as a short-term budget solution, we should be working together to find long-term solutions; our hope is that we can now move forward with those discussions.” CMA believes that the information supplied by the state to CMS did not measure whether and how a patient’s access to care would be impacted or otherwise take into consideration, as required by law, the costs to provide the care. Because California’s Medi-Cal rates are already extremely low and many prescription medications are reimbursed at breakeven rates, many providers cannot afford to participate in the Medi-Cal program as it stands today. A further reduction in the reimbursement rate would further decrease provider participation in the program. Kaiser State Health Facts lists California as the lowest reimbursed state in the nation. Contact: Michelle Rubalcava, (916) 551-2543 or

Medicare News Bipartisan support is growing for funding Medicare SGR repeal with unspent war funds As the House-Senate Conference Committee continues to deliberate legislation to address the 27.4 percent Medicare feefor-service payment cut and extension of unemployment benefits and payroll tax cuts beyond February 29, momentum is growing to repeal the sustainable growth rate (SGR) formula by using the unspent funds from the early withdrawal of troops from Iraq and Afghanistan. There is nearly $800 billion in the Overseas Contingency Operation appropriation. At the California Medical Association’s (CMA) urging, the House Democratic leaders (California Representatives Pelosi, Becerra, Stark and Waxman) announced their full support for the proposal. The Democratic Senate leaders have also expressed their support. Republicans in both houses are also beginning to look on the proposal favorably. Senate Minority Whip Jon Kyl (R-AZ) hopped on board during the Super Committee negotiations, and has since been working behind the scenes to win GOP support. Meanwhile, Rep. Phil Gingrey (R-GA), the co-chairman of the GOP Doctors Caucus, has come around as well. Kyl is a close ally of Senate Minority Leader Mitch McConnell (R-KY). Majority Leader Eric Cantor (R-VA) wants the Doctors Caucus to “take the lead” on this issue, so Gingrey and his fellow House GOP physicians may hold the key to the final piece of the puzzle.

CMA is also working with Senator Feinstein and Congressmen Farr and Bilbray to include the California Medicare Geographic Payment Locality update in the conference agreement. Both California Congressmen Waxman and Becerra are on the conference committee and have been supportive of the California update . Both of these issues need to be addressed by the conference committee and passed by Congress before the deadline of February 29.

CMA goes to Washington, D.C. CMA physician leaders will be in Washington, D.C., February 1315 to lobby Congress and the Centers for Medicare & Medicaid Services (CMS) on the implementation of health reform, including new payment models, stopping the Medicare fee-for-service SGR cuts and Medi-Cal payment reform. The group will be meeting with key Republicans and Democrat leaders as well as new CMS head Marilyn Tavenner. Contact: Elizabeth McNeil, (415) 310-2877 or

(See News, Page 17)

Winter 2012

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CMA Urges Physicians to Call Members of Congress Now! It is imperative that we urge Congress to use military funds to repeal the Medicare SGR now! The Conference Committee must send a bill to Congress for a final vote before February 29. Momentum is building, but we have a long way to go. We must garner more support from the California Republicans and shore up the Democrats. There is only a short window of opportunity. Please call and send a short message to your representatives via email. A short message from hundreds of physicians will have an enormous impact. The military “savings” is an appropriate funding source to repeal the Medicare SGR, which costs over $300 billion. Congress’ failure to address the SGR grows the deficit. If Congress does not use this funding source, they will be forced to cut other Medicare providers to stop the SGR cuts. For more information, see additional CMA talking points and background, and a copy of the Dear Colleague letter. Please call the AMA Grassroots Hotline at (800) 833-6354; plug in your ZIP code and you will be automatically connected to your Member of Congress. Please use the hotline to call Senators Boxer and Feinstein as well. You can send an email to your Representative and Senators via; and Leave your name, specialty and county and tell your Representatives: 1. Please use the unspent military (OCO) funds to REPEAL THE FLAWED MEDICARE SGR! 2. Please cosign the bipartisan Dear Colleague letter from Representatives Crowley and Benishek. 3. Repealing the SGR will reduce the deficit and improve access to doctors for California’s seniors and military families. 4. Physicians cannot sustain a nearly 30 percent payment cut and continue to see patients. Physicians, please take a few minutes this week to make a call. It could make all the difference.

News (Continued from page 16)

Medical-Legal Library Gaining market share of newly insured patients under health reform: A guide for solo and small practices With the influx of approximately 6.5 million newly insured patients in California in 2014 when health reform takes effect, many physicians will want to compete for access to these patients. But how do small and solo practices compete with large health care systems? The California Medical Association (CMA) has created a new medical-legal document, #0206 "Accessing Patients: Marketing and Other Steps Physicians Can Take," to help physicians develop a marking strategy to gain market share of these newly insured patients.

The document will help access the environment or culture of the area where you practice and identify your target audience. The document also takes physicians through the legalities of advertising and how to correctly advertise to a new patient base. Medical-legal document #0206 "Accessing Patients: Marketing and Other Steps Physicians Can Take," as well as the rest of CMA's medical-legal library is free to members in CMA's online resource library. Nonmembers can purchase medical-legal documents for $2 per page. Contact: Samantha Pellon, (916) 551-2872 or

Winter 2012

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GROUP Level Term Life Program


ooking for cost effective life insurance? Merced-Mariposa County Medical Society members may now apply for up to $1,000,000 of life insurance on either a 10- year level term or 20-year level term basis. Rates for the first 10 or 20 years of your coverage are locked in so that you do not have to experience increases in premium solely as the result of getting older.* This results in substantial premium savings during the term of the coverage. After the initial 10 or 20-year term period, you can reapply for coverage at your then attained age or transfer to the regular term life program if you no longer qualify through underwriting. You may also insure your spouse or domestic partner for up to $1,000,000 and your eligible employees for up to $500,000. Each plan also includes two special member services: travel assistance services for medical emergencies when you are traveling away from home;** and a funeral planning and concierge service, at no additional cost to you.*** Call Marsh for more information at 800-842-3761 or email

*The initial premium will not change for the first 10 or 20 years unless the insurance company exercises its right to change premium rates for all insureds covered under the policy with 60 days advance written notice. Underwritten by ReliaStar Life Insurance Company. Policy form LP08GP. **ING Travel Assistance Services provided by Europ Assistance USA, Bethesda, MD 20814 ***Funeral Planning and Concierge Services provided by Everest Funeral Package, LLC, Houston, TX 77056.

58759 (2/12) ©Seabury & Smith Inc. 2012 • AR Ins. Lic. #245544 • CA Ins. Lic. #0633005 d/b/a in CA Seabury & Smith Insurance Program Management • 777 South Figueroa Street, Los Angeles, CA 90017 • 800-842-3761 • •

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The Merced‐Mariposa County Medical Society and Practice Management Institute  are  pleased  to  bring  to  Merced  an  opportunity  to  participate  in  two  workshops  that will provide information essential to the success of the medical practice you  work for.  100% Satisfaction Guaranteed!  For details visit 



The latest news pertaining to physician coding  and reimbursement in 2012 

Mastering the next generation of coding   

More than 200,000 diagnosis codes will replace ICD‐9‐CM in 2013.  While  the  new  codes  will  not  be  released  for  another  year,  every  coder  must  get  familiar  with  the  new  coding  system.    ICD‐10  codes  will  be  much  more  descriptive,  requiring  a  good  understanding  of  both  anatomy  and  medical terminology.  It is not too early to begin preparing your practice.   Learn  the  new  code  characteristics  and  how  they  compare  to  today’s  system.  Find out what the future holds for ICD‐10 and what you need to  know now to get ready. 


This session will provide up‐to‐date information on coding changes, new  and  deleted  edits,  and  guideline  revisions  that  impact  your  practice’s  reimbursement.    Important  recently  released  news  issued  by  Medicare  and the major private carriers will be summarized and explained so that  you  will  be  able  to  obtain  the  knowledge  needed  to  work  “within  the  system.”  Review the most recent version of the National Correct Coding  edits.    Make  sure  that  you  begin  2012  armed  with  the  facts  needed  to  process claims efficiently for the services provided. 


Class Highlights:   Common practice concerns about the upcoming conversion to  ICD‐10‐CM   Creating a timeline for conversion   Documentation requirements 


Class Highlights:   OIG Work Plan 2012 review   Preparing to comply with Version 5010 testing standards   Latest updates on private payer policies and reimbursement 


Wednesday, February 29, 2012   

The Auditorium at the Merced County Department of Public Health  260 E. 15th Street, Merced, California   

COST:  Staff of MMCMS member physicians: $129.00 for one session or $219.00 for both sessions  Staff of non‐member physicians: $209.00 for one session or $359.00 for both sessions  Cash or check payable to MMCMS, 2848 Park Avenue, Suite C, Merced, CA  95348, REQUIRED with registration.   

Continental breakfast will be available at 8:45am and lunch will be provided at 12:00pm. 

REGISTRATION IS REQUIRED BY FEBRUARY 22, 2012  Questions?  Contact Chrisy at (209) 723‐2976 or  Please indicate which session(s) you will be attending:    Coding and Medicare Update 2012   9:00am—12:00pm  Program 17726‐0229  3 PMI CEUs/3 AAPC CEUs    Transitioning to ICD‐10‐CM   1:00pm—4:00pm  Program 17727‐0229  3 PMI CEUs   

Please complete one form per attendee:   

__________________________________________________________  Name   

__________________________________________________________  Phone Number   

__________________________________________________________  E‐mail Address   

__________________________________________________________  Practice Name 

Cancellation Policy: A full refund less a $20.00 processing fee will be issued if cancellation is received 7 or more days prior to program start date.  A 50% refund will be  issued if cancellation is 2 to 6 days prior to start date.  No refund will be issued if cancellation is less than 2 days prior to start date. 

Winter 2012

Page 21

Meeting Schedule February 22, 2012

6:30 p.m.

February 29, 2012 9:00 a.m. 1:00p.m.

General Membership Meeting De Angelo’s Restaurant Office Staff Events Coding and Medicare Update 2012 & Transitioning to ICD-10-CM MCDPH Auditorium

March 19, 2012

6:00 p.m.

MMCMS Board of Governors MMCMS Office

May 21, 2012

6:00 p.m.

MMCMS Board of Governors MMCMS Office

General Membership Meeting You are invited to attend our General Membership Meeting to be held:

Wednesday, February 22, 2012 6:30 p.m.—Social

7:00 p.m.—Dinner

De Angelo’s Restaurant

2000 East Childs Avenue, Merced, California

The Guest of Honor will be:

Paul R. Phinney, M.D. President-Elect California Medical Association Dr. Phinney will present:

CMA: Looking to The Future Mansion for Sale in Merced 5500 sq ft home, custom built in White Gate Estates. 6 bedrooms, 8 baths on a 1 acre lot. Prime location, surrounded by Doctors and Dentists. Contact Ravi Kumar, M.D. at

Winter 2012

Page 23

High-Risk Issues Associated with Lawsuits—and What to do About Them By Karen K. Davis, MA, CPHRM NORCAL Mutual, a member of the NORCAL Group


hat are some of the riskiest areas associated with practicing medicine day-to-day? They may be more common place than you think, and some may be easier to guard against than you imagine. Since issuing its first policy in 1975, NORCAL Mutual Insurance Company has grown from insuring a few hundred physicians in Northern California to serving over 20,000 physicians, medical groups, clinics, hospitals and ancillary healthcare facilities in California, Alaska and Rhode Island. The company has also evolved into the NORCAL Group, a group of malpractice insurance companies with policyholders in many states across the U.S. NORCAL Group companies’ policyholders have access to a wide range of risk management resources designed to help physicians and healthcare facilities identify risks and reduce the chances of incurring medical malpractice lawsuits. To discover trends in professional liability, NORCAL Group relies on its extensive database of closed claims information. NORCAL Group also produces reports compiled from facts garnered during on-site risk assessments. Analyzing statistics from these two sources can give a credible picture of the types of situations and actions that most often lead to litigation for physicians, medical groups, and hospitals.

The Claims Perspective NORCAL Group’s closed-claims database can distinguish various nonclinical issues (that is, problems in processes or communication) that are associated with lawsuits. These associated issues have often complicated the defense of allegations made against doctors and healthcare facilities. Closed-claims data for all NORCAL Group companies’ policyholders for the past two years (July 2009 through June 2011) show the top ten associated issues causing difficulties in claims were: 1. 2.

Problem with history, examination, or work-up. Error associated with interpretation or communication of radiology results. 3. Communication problem between healthcare providers. 4. Comorbid issues (comorbidities complicated treatment of patients). 5. Informed consent issues. 6. Problem with medical records. 7. Failure to follow up on tests. 8. Vicarious liability. 9. Problem with a medical or surgical device. 10. Inadequate facility or equipment.


Handling of after-hours telephone calls (including documentation and communication with covering physicians). 2. Distribution of sample medications. 3. Reporting test and consult results to patients. 4. Use of therapeutic agreements with chronic pain patients. 5. Follow-up processes after hospital discharge. 6. Follow-up processes for return office visits. 7. Documentation of allergies. 8. Making corrections in medical records. 9. Legibility of documentation. 10. Authentication of medical record entries.

Looking for the Overlap While the issues from the field are more specific than those on the closed-claims list, there is a revealing overlap. By looking at the lists closely, we can identify four main areas in which physicians are likely to significantly lower their risk levels if they implement effective risk management strategies. Those areas are: 1. 2. 3. 4.

The remainder of this article will offer tips to help you and your staff members evaluate and decrease your liability exposure related to these four key areas.

Management of Follow-up Processes Follow-up systems are important because physicians have a responsibility to ensure that patients are informed about their conditions and get needed care. Here are some strategies for evaluating and honing your follow-up system. 



The Perspective from the Field As a service to policyholders, NORCAL Group companies send Risk Management Specialists to perform on-site visits to identify risk issues in physicians’ offices and hospitals. The Specialists produce reports that recommend strategies for reducing the specific risks found. In September 2011, NORCAL Group studied aggregate data from a subset of 175 risk assessments conducted in the last two years (between July 2009 and June 2011). The top 10 risk issues revealed in this study were linked to:

Management of follow-up processes. Generation of documentation. Management of medications. Communication with other healthcare providers.


When patients are sent for testing, three areas of concern are: Did the patient comply with the recommendation for testing? Were test results received and reviewed by the ordering physician? Was the patient notified about the results? An appropriate follow-up system provides answers to these questions. Double-check your method for monitoring compliance with appointments. There should be some mechanism in place that requires licensed personnel in the practice to review all no-show appointments to determine which patients must be called and rescheduled. Don’t make the patient solely responsible for making appointments for tests or for calling the office to obtain results; assist them. Your follow-up system for diagnostic tests should include not only a method for confirming that you received the test results but also a process for ensuring that you reviewed the results. The review should be timely. A test result should never be filed until you (as the ordering physician) have (See Lawsuits, Page 24)

Winter 2012


Page 24


(Continued from page 23)


personally reviewed, dated, and initialed it. Institute the policy of notifying all patients of all test results (rather than just reporting abnormals).

Generation of Documentation The purpose of the medical record is to communicate internally and externally about a patient’s health. In addition, in a medical malpractice lawsuit, the patient’s record will be used as evidence. 








Each patient’s chart should be an accurate account of the patient’s history and complaints, physical findings, diagnostic tests, diagnoses, and medical care and treatment. Whether a record is paper-based or electronic, the documentation in it should show the patient’s active problems, data analyzed to understand the problems, and plans for further investigating and handling of the problems. If you are handwriting medical record documentation, you should assess your entries to ensure that they are easy to read. If your notes are not clearly legible, you should consider methods to improve the notes, such as printing, dictation, or typing your notes into a computer-based medical record. If you choose to use dictation, you should read all the typed notes to make certain the transcriptionist has accurately recorded the information before you sign and date the notes. Allergy documentation is harder to miss if it is consolidated in a single area of the record. If the patient reports no allergies, the phrase “no known allergies” or the initials “NKA” should be written or typed in the area designated for documentation of allergies. After conducting an informed-consent discussion with a patient, ensure that there is confirmation of the consent process in the medical record, including a consent form signed by the patient and a description of the content of the informed-consent discussion in the progress or preprocedure notes. Telephone contacts should be documented in the medical record, including calls taken after hours. Information from after-hours calls should be incorporated into the medical record as soon as possible. If there is a mistake in the record, you should correct it by drawing a thin line through the inaccurate words. The original entry should still be readable. Then write the correction clearly and legibly nearby, and initial, date, and time it. Never erase, white-out, or otherwise obliterate any entry in the medical record. Electronic health records should not allow you to delete any previously entered material. Instead, they should have methods for correcting prior entries that preserve the original notes. Once you are notified about a potential liability claim, you should not change, add to, or in any way revise a medical record.



You may lower your liability risk if the sample medications in your office are well controlled. Sample medications should be locked in a cabinet or closet. Limit access to samples by designating specific staff to organize and maintain the sample closet. Do not allow pharmaceutical representatives or other unauthorized people access to the sample closet. Document all dispensed samples in the appropriate patient’s medical record. When you give out samples, labeling them with specific information, including name and quantity of medication, name of manufacturer, physician name and address, patient name, date, and instructions for use, will reduce the risk that a patient will make a self-administration error. You can create label templates and fill in the appropriate information before applying a label to a sample box. When you are treating chronic pain patients with opioids, consider setting up written pain medication agreements with these patients. Such agreements can help you and the patient define and agree on appropriate behavior and hinder addicts from obtaining an unlimited supply of medication.

Communication with Other Healthcare Providers Gaps in communication between treating physicians can cause problems that jeopardize a patient’s well-being and provide the impetus for litigation. Here are some suggestions for remaining aware of a patient’s situation when you are sharing that patient’s care with a colleague. 




If you refer patients to other physicians, have some mechanism in place to see that your referral recommendations are carried out and that the patient was seen by the consultant (or another physician of the patient’s choice). Your follow-up mechanism for referrals should also track your receipt and review of the consulting physician’s report. Communicate in writing with the consultant about the specific consultation request you are making. Preparing a fact sheet with the patient’s clinical information and your impression is an effective way to convey the significant details to another physician. After a patient is seen by a consultant, there must be a clear understanding about who will be responsible for what aspects of the patient’s care and who will order further testing and consultations if these are necessary. If you are a consultant, communicate urgent or significant findings directly to the referring physician and be sure that you both know who will provide clinical follow-up. The communication should be done by phone and in writing.

Conclusion Most of the risk management recommendations in this article are not expensive or hard to put in place. Most focus on setting up systems or protocols and then adhering to them. Taking some time to appraise and strengthen vulnerabilities in your practice or facility will help protect patients and may keep you from a malpractice suit or help you defend against one. NORCAL Group Risk Management Specialists are always ready to help policyholders with risk issues and to support practice changes that lower risk and improve patient safety.

Management of Medications The main medication management issues that have been discovered in office assessments have to do with distribution of sample drugs and establishment of pain management contracts. Some tips in these two areas follow:

Karen K. Davis, MA, CPHRM, is a Risk Management Project Manager with the NORCAL Group, which includes NORCAL Mutual Insurance Company, San Francisco, CA; PMSLIC Insurance Company, Mechanicsburg, PA; and Medicus Insurance Company, Austin, TX. Copyright 2011 NORCAL Mutual Insurance Company. All rights reserved.

CES Resources Available to Physician Members CMA’s Reimbursement Helpline (888) 401-5911 Through this members’ only service, CES provides one-on-one educational assistance and payor advocacy to physician members and their staff. The helpline is staffed by practice management experts with a combined experience of over 125 years in medical practice operations. Practices can call on CMA’s Center for Economic Services reimbursement experts to discuss economic issues affecting their practice, including but not limited to billing and collections, coding and documentation, and managed care contracts. All resources, with the exception of CPR, listed below can be located on our website at CMA’s Practice Resources (CPR) Monthly E-Mail Bulletin – 2011/2012 CMA Practice Resources (CPR) is a free monthly e-mail bulletin from CMA's Center for Economic Services. This bulletin is full of tips and tools to help physicians and their office staff improve practice efficiency and viability. Visit to sign up or view the current issue. Archived issues of CPR are available via our online resource library. CMA Hosted Practice Management Webinars CMA hosts a series of live monthly webinars to educate physicians on a range of topics from health information technology to reimbursement issues. CMA members can access archived webinars and the 2012 webinar calendar on our website at calendar. Webinars are free for CMA members and their staff. “Know Your Rights” Series of one-page print and post documents that summarize the prompt pay legislation sponsored by CMA (AB 1455). Companion seminar available (Know Your Rights) Know Your Rights: Timely Payment State and federal laws require that most payors pay clean claims within specific time frames. California law further requires health plans and insurers to pay interest on claims that are not paid within the required time frame Know Your Rights: Timeframes to Appeal Practice revenue is lost when claims are underpaid, delayed, or inappropriately denied. When your practice learns that a claim has been denied and the reason for the denial, steps should be taken to appeal the claim as appropriate. Following is a summary of timeframes for appeals. Know Your Rights: Quick Guide for Appeals Payors deny claims for a variety of reasons. This document describes some of the more common types of denials and how to respond to them. Know Your Rights: identify and Report Unfair Payment Practices The regulations implementing CMA-sponsored legislation (AB 1455 - Unfair Payment Practices) prohibits health plans and their contracting medical groups/IPAs from engaging in various unfair payment practices. CMA summarizes the unfair payment practices in this one page print and post document. Know Your Rights: Filing a Formal Complaint with the Regulator This is a quick reference guide to assist practices with identifying the appropriate regulator by plan type. The guide includes direct links that can be accessed to file a formal complaint against an HMO, PPO, medical group/IPA or Blue Cross Blue Shield Out-of-State plans. Practice Empowerment Mini Toolkits/Informational Guides Medicare Part B 2012 Important Changes: What They Mean to Your Practice-2011 The Centers for Medicare & Medicaid Services (CMS) issued a final rule on November 1, 2011, that updates payment policies and Medicare payment rates for physicians’ services furnished in 2012. To assist physician offices in planning for billing changes, CMA has developed this guide to highlight changes that may impact physician billing. Companion seminar available (Medicare Changes for 2012) Medicare Electronic Prescribing Overview: Payment Incentives and Payment Reductions - 2011 Medicare introduced an e-prescribing program in 2009 that encourages physicians to electronically transmit their prescriptions. The e-prescribing program provides incentive payments for physicians who e-prescribe and payment penalties for physicians who do not. Starting in 2012, Medicare will begin a 1 percent payment reduction penalty on all Medicare allowed charges for eligible professionals who do not electronically transmit their prescriptions. The penalty increases to 1.5 percent in 2013 and 2 percent in 2014. Medicare Enrollment Guide for Individual Physicians – Updated June 2011 Medicare enrollment processes have changed considerably over the years, and even more so with the introduction of national provider identifiers. The enrollment application process for individuals can be complex and burdensome. CMA has developed this document to guide new physicians through the enrollment process, and to assist enrolled physicians who are making changes or who must revalidate their enrollment.

CES Resources Available to Physician Members...continued Preparing for the New HIPAA 5010 Standards: A Guide for Physicians- 2011 (Join Legal/CES publication) Physician practices may need to make adjustments to the patient data they collect and report in order to comply with a new Health Insurance Portability and Accountability Act (HIPAA) requirement that takes effect January 1, 2012. While the changes primarily impact software vendors and billing clearinghouses, compliance may require medical practices to change some business processes as well. The California Medical Association (CMA) is advising members to familiarize themselves with these regulations and be proactive about making the needed changes to comply prior to the January 1 effective date. Are you ready for the transition to HIPAA Version 5010? - 2011 (Joint Legal/CES publication) Beginning January 1, 2012, physicians and others in the health care industry will be required to use the updated 5010 version of the Health Insurance Portability and Accountability Act (HIPAA) transactions standards to conduct electronic administrative transactions, such as claims submissions, checking eligibility, claims status, remittance advice, and referral authorizations. This resource sheet assists physicians with preparing for the 5010 transaction. 5010 Quick Reference Guide - 2011 CMA surveyed the major payors in California to find out which of them will allow for an extension on the 5010 enforcement deadline. Results, where available, are below. This guide will be updated regularly as new information becomes available Special Investigations Unit Audit Guide - 2011 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. To help physicians understand their rights and responsibilities when it comes to health plan refund requests, CMA has prepared this Special Investigations Unit Audit Guide. Contract Amendments: An Action Guide for Physicians - 2010 This guide is designed to help physicians understand their rights and options when a health plan notifies them of a material modification to a contract, manual, policy or procedure. Payor Solvency Checklist - 2010 To help physicians monitor the financial health of their contracted payors, CMA has put together a checklist available to members. You can also request a hard copy by contacting CMA using the information below. 2010 Guide for Medicare Consultation Code Reporting - 2010 As a result of Medicare’s decision to no longer recognize and pay consultation code services effective 1/1/10, CMA has published a 6-page billing guide that includes an overview of the issue, a code crosswalk, and links to additional resources. CMA Managed Care Consultation Code Quick Reference Guide – Updated October 2011 This is a companion guide to the Medicare Consultation Code Guide (above). CMA surveyed the major managed care payors in California to find out which of them plan to follow Medicare’s lead and eliminate consults. This chart will be updated regularly as new information becomes available. Payor Profiles - 2011 Center for Economic Services has compiled critical information for interacting with the major payors. On each of the payor profiles you will find the important contact numbers, addresses, and links for quick reference for payor interactions. You can use these profiles on-line or print them to keep at your fingertips. These documents are updated annually.       

Aetna Anthem Blue Cross Blue Shield Cigna Health Net Medicare United Healthcare

Timely Access Regulation Guide – 2010 (Joint Policy/Legal/CES publication) The California Department of Managed Health Care (DMHC) recently finalized regulations that require HMO patients to be seen within certain timeframes for various levels of care. The primary intent of these regulations and the underlying legislation is to require HMOs to ensure that their networks of providers have the capacity and availability to provide care to enrollees in a timely manner. Although there will not be a full picture of what physicians need to know regarding contracting or implementation for some time, CMA has published a toolkit to help physicians understand these new regulations and what they could mean for their practices. The toolkit will be regularly updated as new information becomes available.

CES Resources Available to Physician Members...continued Practice Empowerment Toolkits Best Practices Toolkit - 2009 This toolkit offers a series of proven steps that solo and small-group practices can take to improve many facets of their practice, including the delivery of better-quality medical care. It is based on an important premise: that in order to provide quality medical care, a physician practice must be efficient and well run. The toolkit is organized into nine chapters that can be read sequentially or on an as-needed basis. Companion seminar available (What Every Physician/Office Manager Should Know about Their Practice) Taking Charge: Steps to Evaluating Relationships and Preparing for Negotiations - 2005 Payor contract negotiations can be difficult. This guide is designed to guide the physician through t he contract evaluation and negotiation/renegotiation process. This guide also provides the physician and his/her office staff with practical tips and tools to assist with the negotiation, implementation, and on-going management of complex agreements. Companion seminar available (Taking Charge) Other Educational Tools  CMA

Sample Letters

Sample Termination Letter – Patient If the terms of a proposed contract are not acceptable or sustainable, physicians have the right under California law to terminate their agreement with the payor prior to the effective date of the changes. Physicians who decide to exercise their right to terminate their agreement with a payor are encouraged to communicate their decision to with their patients. Physicians may wish to consider using the sample letter CMA has prepared to notify patients of their decision to terminate their contract. Sample Termination Letter – Material Modification to Contract (Payor) If the terms of the proposed contract are not acceptable or sustainable, physicians have the right under California law to terminate their agreement with the payor prior to the effective date of the changes. Physicians who wish to exercise their right to terminate their contract must do so in writing. Physicians may wish to consider using the sample letter CMA has prepared to notify the payor of their decision to terminate their contract. Sample Letter – Request for Copy of Complete Fee Schedule and Detailed Payment Rules California law requires health plans and their contracting medical groups/IPAs to disclose to contracting physicians the amount of payment for each and every service to be provided under the contract. Plans must also disclose the detailed payment policies and rules used to adjudicate claims. CMA has created a sample letter physicians can use to request this information from the payor. Sample Letter – Request for Copy of Signed and Executed Contract, Complete Fee Schedule and Detailed Payment Rules California’s unfair payment practices regulations require health plans and their contracting medical groups/IPAs to disclose to contracting physicians the amount of payment for each and every service to be provided under the contract. Plans are required to disclose this information initially upon contracting, annually, and upon the physician’s written request.  Comparison

of Anthem Blue Cross Access Standards - 2010 In October, Blue Cross announced amendments to their Prudent Buyer contract to comply with the new Timely Access regulations that caused concern with physicians. At CMA’s request, Blue Cross issued clarification on the original contract amendments. CMA also highlights that many of the new state-mandated timely access timeframes are less stringent than Blue Cross’s existing requirements and provides a comparison of the existing Blue Cross standards.

 Managed

Care Contracting CMA offers members free access to, objective analyses of several health plan participating provider contracts. While these analyses are not intended to be exhaustive, they are designed to draw a physician's attention to issues which may warrant further inquiry or clarification. NOTE: CMA is currently updating contract analyses for each of the major health plans in California. These analyses will be posted on the website when they are available. In the meantime, if you have any questions regarding specific health plans contact the reimbursement helpline at (888) 401-5911 or

1. 2. 3. 4. 5.

Anthem Blue Cross of California Prudent Buyer Plan Blue Shield of California Health Net (includes addendum analysis) United Healthcare Cigna – COMING SOON

The Bulletin 2848 Park Avenue, Suite C â—? Merced, California 95348

Winter 2012  

MMCMS's "The Bulletin" Winter 2012 Edition

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