What you need to know about Blue Shield of California's Care1st integration On January 1, 2019, Blue Shield of California will complete the integration of Care1st Health Plan into its operations, and Care1st’s name will change to Blue Shield of California Promise Health Plan. The newly renamed health plan will remain a separate company and a wholly owned subsidiary of Blue Shield of California. Care1st physicians serving Medicare Advantage HMO, Medi-Cal or Cal MediConnect members will not need to contract with Blue Shield of California to continue providing services, and participating physicians will receive a mailed contract amendment later this year that ... October 16, 2018 General, Managed Care Commercial Payors, Payor Contracting, Payor Issues and Reimbursement 0 0 Comment Read More »
Health Net Federal Services continues to address TRICARE transition issues As previously reported, Health Net Federal Services (HNFS) has experienced implementation issues since taking over as the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region on January 1. In recent discussions with the California Medical Association (CMA), HNFS said it continues to address the breakdowns in process and resulting consequences that have impacted TRICARE providers in the areas of provider contracting and credentialing, beneficiary reassignment and provider directory inaccuracies. Updates are as follows: Contracting and Credentialing Because of staffing and operational issues, physicians may have experienced ... September 12, 2018 Managed Care Commercial Payors, Payor Contracting, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
New Medi-Cal provider enrollment system to go live Sept. 4 The California Department of Health Care Services (DHCS) is releasing an update to its Medi-Cal provider enrollment system—called the Provider Application and Validation for Enrollment (PAVE)—on Tuesday, September 4, 2018. The current iteration (2.0) of the PAVE system, launched on November 18, 2016, transformed DHCS’ provider enrollment from a manual paper-based process to a web-based portal that providers could use to complete and submit their applications, verifications and to report changes. Version 2.0 included most physicians and allied provider types. The new 3.0 update will include even more eligible provider ... August 29, 2018 Medi-Cal Payor Contracting, Public Payors 0 0 Comment Read More »
UnitedHealthcare Community Plan preps for entry into additional Medi-Cal and Medicare Advantage markets Looking to potentially enhance its footprint in the Medi-Cal and Medicare Advantage marketplace by 2021, UnitedHealthcare (UHC) Community Plan of California has issued unilateral contract amendments to contracted physicians in seven California counties. Additionally, UHC providers in the seven counties who are not currently contracted for the Medicare Advantage product will receive a combined contract amendment for participation in both UHC Community Plan of California (Medi-Cal) and UHC Medicare Advantage products. As a condition of participation in the Medi-Cal Managed Care request for proposal process in late 2019 or early 2020, ... August 23, 2018 Managed Care, Medi-Cal, Medicare Commercial Payors, Payor Contracting, Public Payors 0 0 Comment Read More »
Health Net Federal Services experiences significant challenges with TRICARE transition On January 1, 2018, Health Net Federal Services (HNFS) became the new Defense Heath Agency (DHA) managed care contractor for the TRICARE West Region, serving approximately 2.9 million beneficiaries in 21 western states, including California. HNFS took over the contract previously held by UnitedHealthcare Military and Veterans’ Services (UMVS). The California Medical Association (CMA) has learned that HNFS has experienced implementation issues related to provider contracting and credentialing, beneficiary reassignment to new primary care managers (PCM), and provider directory inaccuracies. The contracting and credentialing issues in California are reportedly related ... July 24, 2018 General, Managed Care Payor Contracting, Payor Issues and Reimbursement, Practice Management 0 0 Comment Read More »
Health plans terminate relationship with Vantage Medical Group The California Medical Association (CMA) has learned that two health plans, the Inland Empire Health Plan (IEHP) and Molina Healthcare, are terminating their contracts with Vantage Medical Group. Two other plans, Blue Shield of California and Care1st Health Plan, have issued notices of material breach with an intent to terminate. The plans have filed requests with the California Department of Managed Health Care (DMHC) to transfer their enrollees to other delegated groups. According to IEHP’s block transfer filing with DMHC, Vantage engaged in conduct that resulted in the inappropriate delay, ... July 11, 2018 General, Managed Care, Medi-Cal Blue Shield, Commercial Payors, Department of Managed Health Care, DMHC, Payor Contracting 0 0 Comment Read More »
Health Net announces significant policy changes to Medicare Advantage and Medi-Cal managed care product lines Health Net recently announced several new payment policies for its Medicare and Medi-Cal lines of business, effective May 16, 2018. The California Medical Association (CMA) is very concerned with the adverse impact these policies would have on physician practices. The new policies would: Reduce reimbursement of evaluation and management (E&M) services when billed with modifier 25 under the following circumstances: When a minor surgical procedure code is reported on the same day as an E/M code by the same physician, payment for the E/M ... April 5, 2018 General, Managed Care Payor Contracting, Health Nedt 0 0 Comment Read More »
Health plans terminate contracts with EHS and transition patients to other entities As previously reported, the California Department of Managed Health Care (DMHC) issued a cease-and-desist order on December 26, 2017, requiring nine health plans to terminate their contracts with Employee Health Systems (EHS) Medical Group Inc. This order comes after SynerMed—a company closely affiliated with EHS—was accused of blocking patient access to specialists to hold down costs. EHS has 600,000 patients statewide—90 percent of whom are Medi-Cal managed care patients. As required by DMHC, health plans affected by this order were required to submit a transition plan by January 3, 2018, ... February 5, 2018 Managed Care, Medi-Cal Continuity of Care, Department of Managed Health Care, DMHC, Health Plans, Insurance, Medi-Cal, Payor Contracting 0 0 Comment Read More »
Anthem dials back modifier 25 payment reduction policy; delays implementation This past fall, Anthem Blue Cross notified physicians in several states that effective January 1, 2018, it would reduce reimbursement of evaluation and management (E&M) services billed with modifier 25 by 50 percent. The California Medical Association (CMA) quickly jumped into action and coordinated with the American Medical Association (AMA) and the American Association of Dermatologists, along with many other state and specialty organizations, to push back on the proposed change. Due to the overwhelming opposition from organized medicine, Anthem recently announced it would reduce the magnitude of its modifier ... January 29, 2018 General, Managed Care Contract Amendment, Economic Advocacy, Payor Contracting, Anthem Blue Cross 0 0 Comment Read More »
Blue Shield updates fee schedule effective December 1 Blue Shield of California recently announced changes to its physician fee schedule that will take effect December 1, 2017. While the notice indicated that the new rates would be available on the Blue Shield website by October 1, CMA has learned that Blue Shield experienced technical difficulties that will delay the availability of the new rates on the website, until October 9, 2017 (tentatively). The rates will be located under "Helpful Resources," then “Professional Fee Schedule,” then click “Search the Claims Fee Schedule” using a “Date of Service” of December ... October 13, 2017 Managed Care Blue Shield, Payor Contracting 0 0 Comment Read More »
