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.

UnitedHealthcare (UHC) is mailing letters this week to in-network physicians about the managed care company’s physician profiling system, known as  the Premium Designation Program. The letter will include a quality rating, as well as instructions for accessing UHC’s online assessment reports and the deadlines for seeking reconsideration. According to UHC, requests to reconsider for reasons related to integrity must be filed by February 12, 2011. The ratings will be publicly available online on March 16, 2011.

Physicians and practices should carefully review the information that UHC plans to post online.

Click here to read UNC’s recent announcement about the Premium Designation Program.

What should you be doing now to assure your practice is ready for ICD-10 in 2013?  The NCMS Foundation and the NC Medical Group Managers are offering a webinar, Wednesday, January 12, 2011, 12:00 pm – 1:00 pm, that will discuss the early steps your practice will need for the conversion. Leading the discussion will be Sandy Dixon, CPC of Paragon Health, who is certified in CPT and ICD-9 coding, AAPC.

Click here for more information and to register for the ICD-10 webinar, which takes place next week.

What should you be doing now to assure your practice is ready for ICD-10 in 2013?  The NCMS Foundation and the NC Medical Group Managers are offering a webinar, Wednesday, January 12, 2011, 12:00 pm – 1:00 pm, that will discuss the early steps your practice will need for the conversion. Leading the discussion will be Sandy Dixon, CPC of Paragon Health, who is certified in CPT and ICD-9 coding, AAPC.

Click here for more information and to register for the ICD-10 webinar.

A survey by the Global Healthy Living Foundation, http://www.ghlf.org/, a non-profit patient advocacy group, shows that 70 percent of prescription medications are changed by health insurers, denying patients the drugs their doctors prescribe.

According to GHLF Executive Director Louis Tharp, “This disturbing finding is not a simple case of switching a brand-name drug for a generic one, a common and generally accepted practice used for many illnesses, and one GHLF supports. We found that health insurance companies through the U.S. switch one brand-name drug for another simply because the switched drug is cheaper.”

The survey also found instances of patients with chronic conditions who were responding well to a particular drug, but relapse after being switched to a cheaper drug.

GHLF is conducting an additional national survey to measure the incidence of what are known as “fail first practices” where health insurers require a patient to fail on a cheaper drug before being considered for the original drug their physician has prescribed. The Foundation provides a website, http://www.failfirsthurts.org/, that offers information on how patients can avoid having prescription drugs switched by health insurance companies, and how to effectively complain when it happens.

The NCMS has received questions in recent weeks regarding the impact of the Affordable Care Act (ACA) on non-discrimination testing for employer-sponsored health plans. Section 1001 of the ACA amends Sec. 2716 of the Public Health Service Act, extending IRS non-discrimination requirements (IRS Code 105(h)) that previously only applied to self-insured plans to all fully insured, non-grandfathered plans beginning as they renew on or after September 23, 2010.

This means that health plans cannot discriminate in favor of “highly compensated individuals” regarding eligibility to participate in a plan or the benefits offered by plans. The term “highly compensated individual” is defined in the Internal Revenue Code.

For a plan to be considered non-discriminatory with respect to eligibility, it must pass one of three tests.

• 70% of all employees must benefit under the plan
• The plan benefits 80% of eligible employees and 70% of all employees are eligible.
• The plan benefits a non-discriminatory classification of employees.

(Some employees are excluded from these tests, including those who have less than 3 years of service, are younger than 25, are part-time or seasonal employees, those covered under a collective bargaining agreement or non-resident aliens.)

The Internal Revenue Code indicates that a plan must provide the same benefits for both highly compensated and non-highly compensated employees.  A plan is considered to discriminate in terms of benefits unless all benefits provided for highly compensated participants are provided to all other participants.  All dependent benefits available for highly compensated employees must also be available for all other employee dependents. Plans cannot make benefit reimbursements proportional to compensation and the eligibility tests apply to benefits subject to reimbursement not to actual payments or claims.

If optional benefits such as dental and vision plans are offered, they must be offered to all employees with the same or no premium.

Compliance regulations are expected to come from the Dept. of Labor and IRS regarding tax consequences for violation.