The Compliance Committee of the Physicians Advocacy Institute (PAI) convened this week in Chicago to continue its ongoing efforts to improve the relationships and interactions between physicians and health plans, particularly now that the long-running managed care settlements have expired. The Committee identified multiple opportunities for continued advocacy by PAI including tiered networks, health plan investigations of physicians on the basis fraud and abuse, and the various legal challenges to the Patient Protection and Affordable Care Act of 2010.

PAI was formed as a result of the managed care lawsuits that several medical associations filed against the nation’s biggest health plans. North Carolina Medical Society Executive Vice-President and CEO Bob Seligson serves as PAI’s President. PAI formed the Compliance Committee to monitor the health plans and to ensure that they were complied with the provisions of the Settlement Agreements.

The North Carolina Healthcare Financial Management Association (NCHFMA) will hold the North Carolina Health Insurance Institute October 13-24, 2011 at the Sheraton Hotel at Four Seasons in Greensboro. Registration materials are available at http://www.nchfma.org/.

Have you heard about Medicare’s Initial Preventive Physical Examination, also known as the Welcome to Medicare Visit, and Annual Wellness Visit but don’t know how they’re different? Join CMS for a National Provider Call to learn when to conduct these services, who can perform each service, who is eligible, and how to code and bill for each service.

When? Thursday July 21, 2011; 1:30-3pm ET

Target Audience – Physicians, physician assistants, nurse practitioners, clinical nurse specialists, health educators, registered dietitians, nutrition professionals, medical billers and coders and other interested health care professionals.

In order to receive the call-in information, you must register for the call. Registration will close at 1:30pm on Wednesday, July 20, 2011 or when available space has been filled; no exceptions will be made, so please register early.

For more details, including instructions on registering for the call, please visit http://www.eventsvc.com/palmettogba/072111

The North Carolina Chapter Healthcare Financial Management Association will hold the North Carolina Health Insurance Institute October 13-14, 2011 at the Sheraton Hotel at Four Seasons in Greensboro. Registration materials will be made available at http://www.nchfma.org/. Sponsors include Palmetto GBA, UnitedHealthcare, MedCost, Blue Cross Blue Shield of North Carolina, Humana and North Carolina Medicaid.

Earlier this spring, NCMS heard from numerous physicians and practice managers around the state about problems with United HealthCare’s rollout of its Premium Designation Program, or PDP.  This year notification letters were mailed late, physicians were incorrectly associated with practices, and quality metrics were inappropriately applied, to name a few of the problems.

NCMS presented those complaints to UnitedHealth Group and Premium Designation Program executives.  In response, UHG agreed to reconsider many aspects of the Program in order to make it more user-friendly, accurate, and fair for physicians.  Some of those commitments include:

• Ensure that initial notification letters are sent timely and that physicians and practices have ample time to file for reconsideration/appeal.
• Create a state-specific letter that clarifies what, if any, laws or regulations apply to the PDP.
• Clarify the letter sent to the practice to identify the physicians who did and did not receive designation, and how the practice manager may receive delegation to access the reports.
• Refrain from posting a physician’s new rating until any pending appeal has been resolved.  Instead, United may leave the physician’s previous rating posted or post a message stating “Rating under appeal.”
• Faster resolution of administrative errors such as incorrect physicians assigned to the practice, incorrect patients assigned to a physician, incorrect group name, etc.
• Improved reconsideration worksheets that allow for some reasonable amount of physician notes and documents to be submitted regarding a particular episode.

NCMS is pleased that United was willing to receive physician feedback about the PDP, but also to use the feedback to improve future iterations of the program. Urging managed care companies to improve the fairness and accuracy of their physician profiling programs continues to be one of the Medical Society’s main areas of focus.

On Tuesday, the Thomas/Love Settlement Agreement between BlueCross BlueShield of North Carolina (BCBSNC) and the North Carolina Medical Society officially ended. Overall, the Settlement Agreement, which has been in place for four years, has led to improved transparency and communication between the health plan and physicians.

The centerpiece of the Settlement Agreement is Section 7, which required BCBSNC to change many of its basic business practices with regard to physicians. For example, Section 7 includes restrictions on when BCBSNC could seek recoupments, notice and timing requirements for contractual changes, disclosure and notice of claims payment and coding edit practices, and so on. You can review the Settlement and more about the original legal disputes at http://www.hmosettlements.com/.

In the final weeks of the Agreement, NCMS engaged BlueCross in a conversation about its intentions to commit to permanently implementing many of the good practices embodied in the Agreement. In response, BCBSNC has agreed to permanently adopt several key components, including:

• Disclosure of complete fee information via BCBSNC’s secure provider website.
• Reduced prior review and precertification requirements. BCBSNC has committed to work with its self funded clients to limit customization of the prior review list.
• Convene regular meetings between BCBSNC medical directors and physicians to discuss issues facing members of the BCBSNC provider network. The Joint Advisory Group served this purpose under the Settlement, but was recently merged into a modified Physicians Advisory Group.
• Abide by the provisions pertaining to prompt physician credentialing.
• Follow the coding rules under Section 7.20, which discusses the use of modifiers and bundling, and continue public disclosure of significant edits.

Several disputes between physicians concerning BCBSNC’s compliance with Settlement provisions are pending and will continue beyond the expiration of the Agreement. However, physicians and practices will no longer be able to file new disputes against BCBSNC for alleged violations of the Agreement.

Updates, Including the Effect on Your Practice’s Revenue

Palmetto GBA is preparing to assume the North Carolina Medicare Part B workload on May 28, 2011, and has updated the NCMS on the transition: 

• A new Payer Identification Number (11502) becomes effective on the implementation date, May 28, 2011. Medicare providers should begin to submit claims using the new Payer ID on that date.
• The April 1 issue of the Bulletin reported that Palmetto GBA issued a Welcome Letter and Implementation Guide to help Medicare physicians and other providers in the implementation. This applies to services billed on CMS-1500/837B by North Carolina Part B providers currently billing CIGNA. Other Medicare providers will receive information about their implementation over the next several months.
• Processing of EFT agreements is going according to plan.  Palmetto says they are meeting their timelines for getting the agreements processed.  They have processed 80% of all EFT Agreements that they expected to receive from NC Part B providers.  (If your practice hasn’t done this yet, click HERE right now!)  
• 85 claims submitters have been connected to early boarding.  This covers 75% of all providers and Palmetto GBA expects this number to continue to rise in the next week. 
• Important– next week practices will likely see a large infusion of cash from CIGNA as they clear pending claims from their decks.  This will be followed by a period of two weeks of little to no payment from Palmetto.  Be sure your practice plans accordingly.  Read more about the “Claims Payment Floor Release” here: http://cignagovernmentservices.com/partb/pubs/news/2011/0511/cope14634.pdf

Questions should be directed to Palmetto’s Implementation Hotline at (888) 791-1938, or the website www.palmettogba.com/j11b.

This Wednesday Blue Cross Blue Shield NC (BCBSNC) revealed its new campaign, “Let’s Talk Cost,” which encourages all health care stakeholders to stop “scapegoating” on the issue of  increasing health care costs and to start conversations with one another to find solutions.

Using humor in its television, print, and web marketing, BCBSNC hopes to stir discussions on the issue on their website, www.LetsTalkCost.com, with the goal of finding effective cost and quality improvements.  “If we’re going to achieve the goal of affordable health care, everyone – including BCBSNC – must take responsibility for finding solutions,” the company shares in a press release.

NCMS wants to know what your thoughts are on this new endeavor. Take a look at one of their commercials and share your opinion.

The Centers for Medicare and Medicaid Services (CMS) will host a Special Open Door Forum conference call on the 2011 Physician Quality Reporting System (PQRI) and E-Prescribing (eRx) Incentive programs on Thursday, April 14, 2011, 2:30 – 3:30 pm.  Included will be physician reporting and e-prescribing success stories from physicians and the CEO of the Physician’s Business Network in Kansas City, MO. Following the presentations, telephone lines will be opened for Q and A.

To participate in the conference call:

            Dial 1-800-837-1935

            At the prompt, enter the Conference ID 44767416

TTY Communications Relay Services are available for the Hearing Impaired by dialing 7-1-1 or 1-800-855-2880 and a Relay Communications Assistant will help.

An audio recording the conference call will be accessible for downloading beginning on or around May 13, 2011 at http://www.cms.gov/OpenDoorForums/05_ODF_SpecialODF.asp#TopOfPage.

Automatic emails of Open Door Forum schedule updates and FAQs are available at http://www.cms.gov/opendoorforums.

UnitedHealthcare (UHC) has informed the NCMS that its Premium Designation Program Public Designation Display will become available on June 1, 2011 and not March 30, as previously reported. NCMS urges physicians to check your designation on the UHC secure website because some designations may have changed due to updated group affiliated information. UHC says physicians will be notified if their affiliation status is changed.

Because of the change, UHC has extended its reconsideration period to May 1, 2011 to accommodate any physicians who may have questions about their designation determination for display beginning on June 1. Physicians may submit a reconsideration request at any time. However, if the request is not received before May 1, the reconsideration would impact changes already posted on UHC consumer sites. UHC says it will review all requests in an expeditious manner.

If you have not done so already, physicians are asked to register for the new Premium section of UnitedHealthcareOnline.com by following the instructions found at:  https://www.unitedhealthcareonline.com/b2c/CmaAction.do?channelId=a7b0465138a17210VgnVCM1000002f10b10a____.

Physicians, if you encounter any problems with the data UHC provides or any difficulties in communicating with UNC representatives, please contact Conor Brockett at cbrockett@ncmedsoc.org or 800-722-1350.

The NCMS was the first state medical society to alert the AMA concerning delays experienced by physicians in receiving letters from UnitedHealthcare (UHC) informing them of their designation in the UHC Premium Designation Program ( see UHC Notifying MDs about Physician Profiling/Tiering Program; Doctors Have Limited Time to Seek Reconsideration of Information, January 14, 2011 Bulletin). After learning about the delays, the AMA asked UHC to extend the deadline for physicians to appeal their initial ratings. UHC moved the deadline from February 12, 2011 to February 26, but will not post the physician ratings publicly until March 30, 2011. The AMA says physicians can still submit appeals after the February 26 deadline, but there is no guarantee that the appeal process will be completed and the decision reflected in the March 30 posting of the physician ratings. Click here to view UnitedHealthcare’s official announcement.

The 2011 Healthcare Effectiveness Data Information Set (HEDIS®) medical records data abstraction process will begin in March.  CMS and the National Committee for Quality Assurance (NCQA) require health plans to collect and submit HEDIS data about specific health services, such as cancer screenings and comprehensive diabetes care, received by plan members. Of the 73,000 Humana members in North Carolina, 62,100 members qualify for HEDIS review.

Based on Humana’s current 2011 projection, it will be abstracting about 1,000 records.  Approximately 350 providers and practices will be contacted. The number of records requested for each practice will depend upon statistically valid samples. According to Humana, the average number of charts per practice has been limited and a very small number of practices are actually impacted.  The sample will be largely for Medicare Advantage members.

During this process, Humana associates may request your assistance in retrieving information from your medical records. Your practice may be asked to mail or fax copies of chart components for offsite reviews or contacted by a Humana representative to schedule a visit to conduct an onsite review.

As a result of health reform, CMS is requiring Humana and other MA payers and physicians to provide continuous documentation of quality healthcare around HEDIS measures and to address gaps in reporting these quality data. These results will eventually determine reimbursement methodologies that will directly affect the delivery of health care to Medicare beneficiaries. 

For more questions about the HEDIS Review process in North Carolina, contact the Humana Quality Manager, Lynn Trujillo at 770-350-2153 or ltrujillo1@humana.com.

This record review is separate from the Medicare Risk Adjustment (MRA) initiative, which deals with accurate coding of health care conditions for Medicare Advantage members.  For MRA questions, contact Yasmin McLaughlin, MRA Supervisor at 770-350-2287 or ymclaughlin@humana.com.

Last fall, the NCMS learned that State Health Plan (SHP) officials were considering directing its Administrator, BlueCross BlueShield of North Carolina, to recoup payments from physician practices for medical services provided to thousands of newly-discovered ineligible SHP members.  NCMS immediately contacted the SHP to explain that physicians were blameless parties in these transactions, that a massive recoupment effort would be stridently opposed by the physician community, and to urge Plan officials to consider alternate strategies.  Physicians should not be penalized when a health plan is unable to accurately identify its own participants.

On Wednesday the SHP notified NCMS that it would not attempt to recoup payments from physicians, and would instead seek repayment directly from those members who were not properly enrolled in the Plan but represented otherwise to their doctors.

This is the latest development involving the SHP’s comprehensive Dependent Eligibility Verification (DEV) project that began last year.  The verification process, an effort to control costs for Plan members and taxpayers, revealed thousands of members – mostly dependents – who did not meet enrollment criteria but were nonetheless receiving medical services through the SHP.

In what may be a sign of changes to come, Blue Cross Blue Shield of North Carolina (BCBSNC) and UNC Health Care announced this week that they will collaborate to launch a novel patient-centered practice, to be located and opened in Orange or Durham County in the fourth quarter of 2011. According to a BCBSNC news release, the partnership will develop a new type of medical practice that will go beyond the “medical home” and will enable teams of health care providers to work collaboratively with patients and families in delivering high quality, coordinated care for about 5,000 BCBSNC members.

An expanded set of services are expected to be included:

• Non-traditional visit formats (e-visits, televisits, home monitoring)
• On-site mental health
• On-site nutritionist
• On-site pharmacy and medication management
• On-site laboratory
• Case management and coordination of care for patients requiring hospitalization
• Group and educational visits
• Extended weekday and weekend hours
• State-of-the-art information technology

Read more about the BCBSNC-UNC Health Care announcement in these reports (click headline to view story):

UNC Health, BCBS plan joint facility, by Alan M. Wolf, 1-11-11, The News & Observer 

Blue Cross, UNC Health to set up new NC practice, 1-11-11, WRAL-TV

BCBSNC News Release

As we launch into a new year, the federal government also begins the next stage of Affordable Care Act (ACA) implementation. Below you’ll find a brief update of the provisions set to begin implementation this calendar year. All provisions are effective as of January 1, 2011 unless otherwise noted.

Insurance

• Insurers required to pay rebates if target medical loss ratio is exceeded.
• Health and Human Services to begin awarding grants to states for the establishment of American Health Benefit Exchanges and Small Business Health Options Program Exchanges. Effective March 23, 2011.
• CLASS (Community Living Assistance Services and Support Act) Program is established as a voluntary program for purchasing long-term care insurance.
• Over-the-counter drugs not prescribed by a doctor are excluded from Health Reimbursement Accounts and Flexible Spending Accounts.
• 20% tax on pre-tax distributions from HRAs or FSAs that are not used for qualified medical expenses.

Medicaid

• States will now have the option to permit certain Medicaid enrollees to designate a provider as their health home. States will receive 90% FMAP for 2 years for these services. 
• Health and Human Services can begin providing 3 year grants to states to develop chronic disease prevention programs under Medicaid.
• Prohibition on federal payments to states for Medicaid services related to certain hospital-acquired infections.
• State balancing incentive program created to provide enhanced FMAP payments for non-institutionally based long-term care services.

Medicare

• 10% bonus payments for primary care services and general surgeons in health professional shortage areas begin.
• Funding for the Independent Payment Advisory Board becomes available October 1, 2011.
• Waived deductible for colorectal cancer screenings and the elimination of cost-sharing for covered preventative services.
• Pharmaceutical manufacturers must begin providing a 50% discount on brand-name drugs filled in the Part D coverage gap.
• Part D premium subsidies for high-income beneficiaries reduced.
• Medicare Advantage payments restructured by phasing-in lower fee-for-service rates.  Prohibits plans from imposing higher cost-sharing requirements on some benefits.

Miscellaneous

• Chain restaurants and vending machines required to disclose nutritional content of standard menu items beginning March 23, 2011.
• Unused GME residency slots will be redistributed beginning July 1, 2011.