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"Where California Oncologists Go For Answers!"
A collaborative publication of the
Medical Oncology Association of Southern California, Inc.
and the
Association of Northern California Oncologists, Inc.
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This Weekly's Hot Topics
- Final deadline to enroll in a 2018 Marketplace plan is December 15. (National News)
- 12/31/17 deadline to participate, or not, in Medicare for 2018. (CMS News)
- Advocacy Alert! Contact your Senators & Representatives! (National News)
- Blue Shield is automatically reprocessing the affected claims (California News)
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California News
- Earlier this year, the California Medical Association (CMA) began receiving calls from physician offices concerned that Blue Shield of California was not correctly paying claims under the state's new out-of-network billing and payment law (AB 72). AB 72 requires fully insured commercial plans and insurers to make "interim payments" to non-contracted physicians for covered, non-emergent services performed at in-network health facilities, and places limitations on the ability of physicians in such circumstances to collect their full billed charges.
The interim rate is defined as the greater of the average contracted rate or 125 percent of the amount that Medicare reimburses on a fee-for-service basis for the same or similar services in the geographic region in which the services were rendered. The new law also requires payors to honor assignment of benefits and issue the interim payment directly to physicians.
However, physicians were reporting that Blue Shield was not paying the correct interim payments and was also issuing payment to the patient rather than to the physician.
CMA reached out to Blue Shield regarding the reports and has learned that both issues were due to manual claim processing errors. The cause of the incorrect payment amounts was related to processers not picking up the correct units billed.
Blue Shield is automatically reprocessing the affected claims
. The reprocessing project began mid-November and is expected to be completed within four weeks. While physicians do not need to submit appeals, you are encouraged to create a reference list of all affected claims to ensure that all claims are eventually paid correctly.
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- Noridian/JEMAC has posted more updates to its website:
* MLN Connects
Announcements--Claims, Prices & Codes--First Breakthrough-Designated Test to Detect Extensive Number of Cancer Biomarkers; Quality and Cost Measures under Consideration: CMS Releases List for 2018 Pre-Rulemaking; Hospice Provider Preview Reports: Review by December 30; Quality Payment Program Hardship Exception Application Deadline: December 31; Quality Payment Program Resources; Extreme and Uncontrollable Circumstances Policy for MIPS Clinicians in 2017; Medical Record Documentation: Helpful Clinical Templates and Data Elements
Claims, Pricers & Codes--January 2018 Average Sales Price Files Available
Events--
Publications--Advance Beneficiary Notice of Nonycoverage Interactive Tutorial Educational Tool-Revised; Medicare Advance Written Notice of Nonycoverage Booklet-Revised
* Parenteral Iron Administration Coverage in Non-Dialysis Usage
* Positron Emission Tomography Scans Coverage-R12
* Radiopharmaceutical Fee Schedule 2018 Updates
* Telehealth Services: Elimination of GT Modifier CR10152
- Upcoming Noridian/JEMAC webinars include:
* Modifier 59, NCCI, and MUE Webinar (December 13)
* Understanding National and Local Coverage Determinations Webinar (December 13)
* Top Provider Inquiries and Solutions-Part 2 Webinar (December 13)
* Telehealth Services Webinar (December 14)
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DMHC News
- The California Department of Managed Health Care (DMHC) took enforcement action including a $5 million fine-against Anthem Blue Cross for a systemic failure to resolve consumer grievances in a timely manner. This enforcement action is the result of deficiencies identified in medical surveys conducted by DMHC, as well as 245 specific grievance system violations identified by the DMHC's Help Center during the investigation of consumer complaints from 2013 through 2016.
Under California law, plans are required to recognize an expression of dissatisfaction as a grievance, or complaint. Instead, calls to Anthem's customer service system resulted in repeated transfers, as well as unfulfilled promises that the plan's representatives would return calls. It was not until enrollees sought assistance from DMHC, sometimes months after the services in question, that Anthem finally paid certain claims.
Like the grievance process available to patients, physicians can submit written appeals
to the plans when services are denied. Plans are required to have fast, fair and cost-effective dispute resolution processes to resolve physician disputes. Many physicians, however, report that when they submit appeals to Anthem, the dispute process is simply a rubber stamp to uphold the initial denials, without effective resolution, resulting in unresolved complaints that delay needed care.
DMHC's enforcement action comes on the heels of a pattern of recent problematic policy changes and restrictions negatively affecting California physicians and their patients' access to high-quality and timely care, including:
MOASC, ANCO and the CMA continue to closely monitor this situation to ensure that payors employ a "fast, fair and cost effective dispute resolution process" as required by CA law:
The failure of a plan to comply with the requirements of these laws is a basis for disciplinary action against the plan. The civil, criminal, and administrative remedies available to the Director under the Knox-Keene Act and the unfair payment pattern regulations are not exclusive, and may be sought and employed in any combination deemed advisable by the Director to enforce the provisions of this regulation. (28 C.C.R. §1300.71.38(m).
Please provide MOASC with YOUR healthplan grievances. Please send them to
[email protected]. Thank you.
- The California Department of Managed Health Care (DMHC) has taken enforcement actions including a $322,500 fine against California Physicians' Service (Blue Shield of California) and a $135,000 fine against Care 1st Health Plan for failing to identify, timely process, and resolve consumer grievances. The plans have also failed to fully and timely provide information to the Department during the investigation of these consumer complaints.
"The health plan grievance and appeals process is structured to ensure that consumer complaints are resolved in a timely manner, and that consumers are made aware of their right to appeal to the DMHC," said DMHC Director Shelley Rouillard. The DMHC identified cases where the health plans deprived consumers of their grievance and appeals rights and/or failed to fully and timely provide information to the Department during the investigation of member complaints.
For additional information on these enforcement actions, visit the links below:
Blue Shield of California:
http://wpso.dmhc.ca.gov/enfactions/docs/3034/1512742849620.pdf
Care 1st Health Plan:
http://wpso.dmhc.ca.gov/enfactions/docs/3033/1512742567108.pdf
In California, consumers have many health care rights, including the right to know why a plan denies a service or treatment, and the right to file a grievance if they disagree. Health plans are required to have grievance and appeals systems to assist consumers in resolving these issues.
If a consumer is experiencing an issue with their health plan or is having difficulty accessing care, they can file a grievance with their health plan. If they are not satisfied with their health plan's resolution of the grievance or have been in their plan's grievance system for 30 days, they should contact the DMHC Help Center for assistance at 1-888-466-2219 or online at www.HealthHelp.ca.gov.
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- MARK YOUR CALENDAR, for MOASC's Spotlight On®Hematology,Saturday, January 27, 2018 in Huntington Beach.MOASC's Spotlight On series presentation brings highlights of the 2017 ASH annual meeting. MOASC awarded educational grants to 3 UCI Fellows who attended the ASH Annual in Atlanta, GA on December 9 - 12, 2017. They & UCI faculty will present their discoveries through interactive discussions on ASH highlights. For more information and to register please contact the MOASC Office at [email protected].
- You are cordially invited to MOASC's 3rd Annual Oncology Summit®, Harnessing the Power of Immunotherapy.March 3, 2018 at the Waterfront Hilton, Huntington Beach. Topics & speakers:
*Head and Neck
Ezra Cohen, MD, UCSD *Colon Cancer Marvan Fakih, MD, COH *Lung Cancer Karen Reckamp, MD, COH *Breast Cancer Sara Hurvitz, MD, UCLA *Melanoma Omid Hamid, MD, The Angeles Clinic & Research Institute.
- As you have just read in California News and DMHC News, above, without feedback from physicians, DMHC will not be able to fight on your, and your patient's, behalf.
Please forward your problem claims or issues to the MOASC Office
[email protected]
, to submit to the DMHC or DOI.
- Listen to MOASC President, Warren Fong, M.D. interview from Sunday, December 3. You can hear it here: https://soundcloud.com/sunday-morning-newsmakers/sunday-morning-newsmakers-12-03-17-seg-4. Dr. Fong spotlights a major problem with the federal 340B drug discount program, which was started with the best intentions but, due to lack of oversight and no accountability, is allowing many hospitals and pharmacies to make a profit at the expense of many low-income uninsured Americans.
- Receive a $10 gift card! MOASC is conducting a quick Communications Survey, and we need you help to better serve you and to know how we are doing. We are simply looking for your opinions. The survey should take less than 5 minutes to complete for you to receive your $10 gift card.
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ANCO's 2017
Annual Report is now available online at
www.anco-online.orgAR2017.pdf. A copy was also mailed to ANCO physician members and Corporate Member representatives the last week of November.
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ANCO's Medicare Reimbursement for Oncology 2017 & Revenue Cycle State of the State with Bobbi Buell takes place in San Jose on January 3 and Sacramento on January 4. Learn the latest information impacting Medicare's reimbursement for oncology in 2018 and what to do about your denial rate, days to pay, and days to file using data specific to northern California. This will be a unique opportunity to get benchmarks that you can use for billing and appeals at your facility. Download the meeting announcement and registration form at
www.anco-online.org/MedicareUpdate2018.pdf.
- ANCO, in association with the Organizing Committee of the San Antonio Breast Cancer Symposium and Encore Medical Education, is hosting the
Best of San Antonio Breast Cancer Symposium San Francisco (Best of SABCS San Francisco) at The Claremont Hotel on Saturday morning, January 27, 2018. Hope S. Rugo, M.D., is the Regional Director for the Best of SABCS San Francisco. For more information and to register, visit
https://s3.goeshow.com/encoremededu/BestofSABCSSanFrancisco2018/ereg101626.cfm?pg=home.
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The 18th Multidisciplinary Management of Cancers: A Case-based Approach returns to the Silverado Resort and Spa in Napa on March 16-18, 2018. The meeting is sponsored by the Association of Northern California Oncologists, Stanford Cancer Institute, UC Davis Comprehensive Cancer Center, and UCSF Helen Diller Family Comprehensive Cancer Center. Go to
www.multicancers.org for more information, to register, and arrange for housing.
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Advocacy Alert
!!!
1) Stop the Medicare Sequester Cut!
Call your member of Congress today.
With the passage of the tax bill, Congress has done the unthinkable - triggering a cut to Medicare payments (referred to in Washington as a "sequester" cut). Call Congress and let them know the Medicare sequester must be stopped. This will have a dangerous impact on cancer care in the United States, reducing access and increasing costs for patients. We need your help: Call Congress today and let them know the Medicare sequester must be stopped! Use COA's Sequester Action Hotline at (202) 831-3525 to be automatically connected.
There are provisions in the bill that would impact access to care for patients with oncologic & hematologic diseases and disorders. Congress aims to pass the new bill before the holiday recess. It is vital that we make our voices heard as loudly and often as possible.
Please call or email your Representatives and Senators to ask them to oppose the provisions in the tax legislation that are harmful to patients. Email your Representatives and Senators. This will not take much time, but will have a huge impact.
If you plan to call your Representative or Senator, here is a sample script.
"Hello, I am a constituent and am calling to ask the Representative/Senator to oppose the provisions in the tax legislation that are harmful to access to care for the patients I serve. Specifically, oppose the repeal of the individual mandate, the repeal of the Orphan Drug Tax Credit, the repeal of the medical expense deduction, and oppose any legislation that would cause cuts to Medicare."
2) Contact your Senators and House members to vote in favor of repeal of the Independent Physician Advisory Board! To ensure Congress hears that IPAB needs to be repealed this year, your action is needed! Urge Congress to incorporate IPAB repeal in any legislative vehicle that must move before year's end.
Call your Senator and Congressman today at 202-224-3121.
- DEADLINE:
The final deadline to enroll in a 2018 Marketplace plan is December 15.
Note: If you don't wish to use an agent or broker to select a plan, you can find other forms of assistance using our Find Local Help tool.
- As the California Medical Association (CMA)
recently reported, Anthem Blue Cross notified physicians in several states that it will begin reducing reimbursement of evaluation and management (E&M) services billed with modifier 25 effective January 1, 2018. Concerned with the adverse impacts of this new policy upon physicians the American Medical Association (AMA), along with many other state and specialty organizations, is coordinating to push back on the proposed change. In response to the Anthem policy announcement, AMA recently adopted policy to "aggressively and immediately advocate through any legal means possible, including direct payer negotiations, regulations, legislation, or litigation, to ensure when an evaluation and management (E&M) code is appropriately reported with a modifier 25, that both the procedure and E&M codes are paid at the non-reduced, allowable payment rate."
Physicians are urged to thoroughly review and assess the impact any proposed modifications to their contract would have on their individual practices.
To assist physicians in analyzing this change, CMA has developed a simple worksheet that will help calculate the net financial impact to their practice resulting from this change. The Modifier -25 financial impact worksheet is available free to CMA members at www.cmanet.org/ces.
California physicians should be aware that California law requires health plans and their contracting medical groups/IPAs to provide 45 business days' advance notice of a material change to a contract, manual, policy or procedure (28 C.C.R. §1300.71(m)). A change is considered "material" if "a reasonable person would attach importance [to it] in determining the action to be taken upon the provision." Physicians have the right to terminate the agreement prior to the implementation of the change if the physician does not agree to the proposed change (Health & Safety Code §1375.7; Insurance Code §10133.65). For more information on physicians' rights and options when a health plan makes a material change to a contract, manual, policy or procedure, see CMA's resource titled
, "Contract Amendments: An Action Guide for Physicians."
- NIOSH recently released the National Framework for Personal Protective Equipment (PPE) Conformity Assessment (CA)-Infrastructure document. The document provides a framework to assist in developing, structuring, and managing PPE CA in the workplace. The framework can be tailored and broadly applied to all PPE that protects from a variety of risks regardless of the hazard, type, or environment. This document represents the first in a series of documents supporting the National Framework for Conformity Assessment of PPE. NIOSH will use this document series to publish additional documents related to the development, implementation, and use of conformity assessment programs for PPE.
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CMS News
- Once again, it's time for physicians to decide if they want to make changes to their Medicare participation status. Physicians have until December 31, 2017, to make changes for the 2018 participation year. Physicians have three choices regarding Medicare: Be a participating provider; be a non-participating provider; or opt out of Medicare entirely.
Physicians who want to change their participation status for 2018 must send a letter to their Medicare contractor, postmarked by December 31, 2017.
- The Centers for Medicare and Medicaid Services (CMS) recently published the final Medicare Physician Fee Schedule for 2018. Overall, there are many positive changes in the final rule, including the reduction of penalties under the flawed Value Modifier (VM) program, the expansion of coverage for telehealth services, the delay in implementation of the Appropriate Use Criteria (AUC) for imaging, and the reduction of documentation requirements for Medicare Shared Savings Program accountable care organizations. (CMA also fully supports the transition to the new geographic payment regions in California). In the proposed rule CMS announced its "Patients Over Paperwork" initiative, designed to reduce the regulatory burden on physicians, and the Meaningful Measures initiative, which aims to ensure that clinical quality measures evaluate only core issues, and invited physicians to submit ideas for regulatory, policy, practice and procedural changes to improve the health care system to reduce unnecessary burdens for clinicians, patients and their families. CMS is working on an easier quality measure reporting process for providers, and stressed that improving EHR interoperability and usability will require collaboration between health IT developers and providers. EHR Intelligence
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CMA submitted its "Top 10 List for Regulatory Relief" to CMS and strongly urged CMS to provide immediate relief because it is causing a significant and disturbing trend in physician burnout. Click here to read the the American Medical Association (AMA) summary.
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Affiliate Association News
- 2018 Highlights of ASH®. Get a synopsis of the top hematology research presented at the latest ASH annual meeting and learn how it can help improve your patient management and care strategies at Highlights of ASH. For more information or to register, click here.
- The second annual ASCO-SITC Clinical Immuno-Oncology Symposium, January 25-27 in San Francisco, will feature more than 40 expert faculty discussing the latest clinical and translational advances in immuno-oncology. These specialists will facilitate in-depth discussions on cutting-edge research currently shaping the clinical application of immunotherapy, as well as provide insight into what this research means for future patient care.
- ASCO seeks applications for volunteers at its ASCO Volunteer Portal https://volunteer.asco.org. Your application will be used for all upcoming Volunteer Corps opportunities and 2018 committee consideration. Apply by January 31, 2018 for 2018 committee consideration.
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NCCN has published updates to the below.
For the complete updated versions, please visit
NCCN.org. Recent updates include: B-cell lymphomas (V7.2017), kidney cancer (V2.2018), prevention and treatment of cancer-related infections (V1.2018).
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- AstraZeneca informs ANCO and MOASC that CMS has assigned HCPCS Code C9492 (10mg) to Imfinzi.
- Celgene informs ANCO and MOASC that the United States Food and Drug Administration has granted bb2121, anti-B-cell maturation antigen (BCMA) chimeric antigen receptor (CAR) T-cell therapy, breakthrough-therapy designation for previously treated patients with relapsed or refractory multiple myeloma (MM).
- EMD Serono informs ANCO and MOASC that CMS has assigned HCPCS code J9023 (10mg) to Bavencio effective for dates of service on or after January 1.
- Foundation Medicine informs ANCO and MOASC that the United States Food and Drug Administration has approved and granted Cdx (F1CDx) breakthrough designation and CMS has proposed coverage of F1CDx.
- Genentech BioOncology informs ANCO and MOASC that CMS has assigned HCPCS code J9022 (10mg) to Tecentriq.
- Genentech BioOncology also informs ANCO and MOASC that the United States Food and Drug Administration has approved Avastin for the treatment of adults with glioblastoma that progressed following prior theory (referred to as recurrent disease).
-Gilead Sciences announced last week that it plans to acquire Emeryville startup Cell Design Labs. It is the second move by Gilead in recent months to invest in cutting-edge cancer treatments known as CAR T cell therapy. In August, the company announced plans to acquire Santa Monica's Kite Pharma. San Francisco Chronicle
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MOASC CALENDAR
Spotlight on Hematology
January 27, 2018
Huntington Beach, CA
Oncology Summit
March 3, 2018
Huntington Beach, CA
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(San Francisco, January 18-20)
(San Francisco, January 25-27)
(San Francisco, February 8-10)
(Napa, March 16-18)
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The
Medical Oncology Association of Southern California
(MOASC) is a leading oncology society that advances and protects the ability of cancer patients to obtain, and the ability of the oncology physicians to provide, optimal cancer care. The
Association of Northern California Oncologists
(ANCO) is an association of hematologists/oncologists dedicated to promoting high professional standards of cancer care by providing a forum for the exchange of ideas, data, and knowledge.
The material contained in the
California Oncology Weekly
is intended as general information for ANCO and MOASC members. Because diagnostic, treatment, contracting, coding, and billing decisions should be made on a case-by-case basis, any such information contained in the
California Oncology Weekly
may not apply in any given situation. Members are encouraged to contact their own consultants or advisors to obtain specific advice on matters relating to contracting, coding, and billing. The information contained in
California Oncology Weekly
should not be used as a substitute for such advice.
This publication provides a summary of regulations affecting oncology and its business practices. Reading this newsletter does not substitute for understanding regulations and verifying the validity of every claim. This information is time-sensitive and is subject to change. MOASC or ANCO accepts no liability for any statements or articles herein.
CPT codes are owned and trademarked by the American Medical Association. All Rights Reserved.
MOASC: P.O. Box 161, Upland, CA 91785 | P (909) 985-9061 | F (909) 804-5006| www.moasc.org
ANCO: P.O. Box 151109, San Rafael, CA 94915 | P (415) 472-3960 | F (415) 472-3961 | www.anco-online.org
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