Wednesday, January 16, 2019

Nondiscrimination Statement Posting

Physicians who provide services to Medicare or Medi-Cal patients must comply with new nondiscrimination posting requirements effective October 16th. Here are the steps RCMA recommends for compliance:

1. Read the members only FAQ: Section 1557 Nondiscrimination Final Rule: Notices of Consumer Rights and Taglines

2. Download the Notice of Nondiscrimination in English along with the Tagline Statements with the 15 top languages spoken in California.

3. Customize the Notice of Nondiscrimination and tagline statements with your practices information:

  • Your practice name [Name of covered entity]
  • Your phone numbers (use your office number)
  • TTY (TTY: 1-xxx-xxx-xxxx) if your office has one.

4. If you have 15 or more employees you must also:

  • Designate a responsible employee “Civil Rights Coordinator” to coordinate the practice’s efforts to comply with and carry out its responsibilities under Section 1557. (Note: the taglines must include the phone number for the practice’s designated “Civil Rights Coordinator”)
  • Adopt Grievance Procedures to provide for prompt and equitable resolutions of any allegations of Section 1557 violations. See OCR Sample Grievance Procedures.

5. Post the Non Discrimination Notice along with the 15 Tagline Statements in conspicuous physical locations where the physician practice interacts with the public (See FAQs for more details)

6. Submit an Assurance of Compliance form to OCR

A couple of additional resources include:

If you still have additional questions, please contact our Physician Advocate Mitzi Young at, (888) 236-0267, (909) 654-0381-mobile or CMA Legal at (800) 786-4262.

Why it’s important to verify your patients' eligibility and benefits for 2016

With the new year soon upon us, physicians are urged to be diligent in verifying patients' eligibility and benefits to ensure they will be paid for services rendered. The beginning of a new year means calendar year deductibles and visit frequency limitations reset. With open enrollment there may also be changes to patients’ benefit plans, or patients may even be covered by a new payor.

The new year also brings a host of other challenges that could affect your ability to be paid:

  • Medicare patients can modify their enrollment choices from October 15 through December 7, allowing them to switch between Medicare fee-for-service and Medicare Advantage, or switch from one Advantage plan to another.
  • The Covered California open enrollment period began November 1 and runs through January 31, 2016. Covered California estimates it may enroll more than 300,000 new enrollees during the 2016 open enrollment period. However, existing enrollees also have the option to change plans and/or products.

Along with the 10 existing plans, two new plans are offering coverage on the exchange in 2016. United Healthcare and Oscar are entering the exchange marketplace for 2016 in select regions.

It’s important that physicians and their staff understand their participation status in the various exchange products offered in their areas in order to advise patients before scheduling as to whether they are participating in the patients' plans. For detailed instructions on how to check physician participation status, see CMA’s toolkit, Covered California: Know Your Participation Status, free to CMA members in our exchange resource center at Contact information for each exchange plan is also included in the toolkit, should practices have additional questions about participation status.

Don’t get stuck with unnecessary denials or an upset patient. Do your homework before the patient arrives by obtaining updated insurance information at the time of scheduling, if possible, and making copies of the insurance card at the time of the visit.

And don't forget that deductibles are typically based on the calendar year and will reset on January 1. Many of the exchange/mirror plans have high deductibles (e.g., $5,000 deductible on the Bronze plan), as do some employer-based plans. This reinforces the importance of verifying patient eligibility – particularly for exchange patients – each time they are seen. Best practice is to communicate with patients upon scheduling to remind them that their plan has a deductible that may be resetting on January 1 and, if that is the case, payment will be due at the time of service. If you offer an appointment reminder service, remind the patient if payment is expected at the time of service. Failure to collect deductibles, copays and coinsurance at the time of service can be very costly for a practice as your ability to collect can decrease significantly after the patient leaves the office.

Taking these proactive steps to protect your practice by preventing denials, delays in payment and disgruntled patients goes a long way toward ultimately saving time and money. 

RCMA/CMA Works with CMS to Mitigate Medicare ICD-10 Disruptions

With implementation of the ICD-10 code set just around the corner, many physicians have been understandably wary about the transition and the potential for payment disruptions and claims processing errors that could interfere with patient care. Fortunately, the RCMA/CMA – working closely with the American Medical Association (AMA) and other medical associations – has secured provisions that will ease this transition, particularly for physicians in practices with limited resources.

Thanks to RCMA/CMA advocacy, the Centers for Medicare & Medicaid Services (CMS) recently announced that it will provide a one-year grace period during which it will allow for flexibility in the Medicare claims payment, auditing and quality reporting processes as the medical community gains experience using the new ICD-10 code set. The ICD-10 implementation date of October 1, 2015, has not changed.

The changes announced include: Claim denials: Medicare review contractors will not deny claims based solely on the specificity of the ICD-10 diagnosis code as long as a valid code from the right family of codes is used. Moreover, physicians will not be subject to audits as a result of ICD-10 coding mistakes during the grace period.

Quality reporting: Physicians also will not be penalized under the quality reporting programs for errors related to the additional specificity of the ICD-10 diagnosis code, again as long as a code from the correct family of codes is used.

Advance payments: If Medicare contractors are unable to process claims within established time limits because of administrative problems, such as contractor system malfunction or implementation problems, advance payment may be available to keep resources flowing to physician practices.

ICD-10 communication center: CMS will set up a communication center to monitor the implementation of ICD-10 in an effort to quickly identify and resolve issues related to the transition. As part of the center, CMS will have an ICD-10 ombudsman to help receive and triage physician and provider issues.

It's Finally Over! The Medicare SGR is Dead!


After a decade of battling, the U.S. Senate, in a whopping vote of 92-8, passed H.R. 2, the monumental, bipartisan Medicare SGR Payment Reform and Children’s Health Insurance Program (CHIP) Reauthorization Act. Both California Senators Feinstein and Boxer voted in the affirmative. Two weeks earlier, the U.S. House of Representatives adopted the legislation in a landslide vote of 392-37. This was a rare, bipartisan achievement in a deeply divided Congress. RCMA, CMA, AMA and more than 780 state and national physician organizations supported the bill. In 2013, the policy was jointly developed on a bipartisan basis by the three House and Senate health committees. This year, U.S. House of Representatives Speaker John Boehner (R-OH) and Minority Leader Nancy Pelosi (D-CA) are credited with negotiating the final budget offsets to fund the SGR bill.

RCMA/CMA extends a sincere thank you to all physicians for the extraordinary campaign this last decade to end the SGR. We have kept up the fight these last two years to hold Congress’ feet to the fire to develop a comprehensive bill to reform Medicare physician payments. The unity within organized medicine finally put this over the finish line. Moreover, 52 out of 54 Members of the California Congressional delegation voted to support physicians. This is an incredible achievement in one of the most dysfunctional Congresses in history.


While H.R. 2 is far from perfect, it represents a significant improvement over the current Medicare program which mandates penalties up to 13% in the coming years with no opportunities for payment updates or bonuses. This bill consolidates the burdensome reporting programs and reinstates significant bonus payments. By repealing the SGR and providing annual updates, it provides stability to physician practices that allows for longer term planning. Significantly, it allows physicians to design new payment systems that work for physicians and patients instead of government bureaucrats. And it mandates physician involvement in defining and developing quality measures. Moreover, once the costly SGR is repealed, it will be much easier for physicians to work with Congress to make improvements to the payment system (such as increasing the annual update) at a lesser cost. The enormous cost of the SGR has been a barrier to making any improvements.

Note that Medicare should begin processing claims today for services provided in April at the rates that were effective before the 21 percent cut was scheduled to take effect. Under the provisions of H.R. 2, the fee schedule conversion factor will be increased by 0.5 percent on July 1, 2015, and by another 0.5 percent on January 1, 2016.

House Landslide Vote to Pass SGR

Today, RCMA/CMA congratulates the U.S. House of Representatives for passing monumental Medicare reform and the Children’s Health Insurance Program (CHIP) extension, and urgently asks their colleagues in the Senate to do the same before spring recess. The 392-37 vote clearly shows that now is the time to make Medicare reform a reality.

The legislation, H.R. 2, known as the “The Medicare and CHIP Reauthorization Act,” will reform the broken Medicare sustainable growth rate (SGR) physician payment system and extend the expiring Children’s Health Insurance Program. Both of these important reforms will help to improve access to doctors in California for five million seniors on Medicare, one million military families on TriCare and the nearly one million uninsured children currently covered by CHIP.

“It is imperative that the House AND the Senate act before the 21 percent SGR Medicare payment cut takes effect on March 31,” said Luther Cobb, M.D., CMA president. “A drastic cut to physician payments will result in decreased access to care for some of our country’s most vulnerable patients. It’s crucial to the success of our health care delivery system that the bill passes before Congress goes home.”

The SGR legislation is nearly identical to the bipartisan, bicameral Medicare physician payment reform package that three Congressional committees unanimously approved in the last Congress and more than 750 state and national physician organizations, including CMA, supported.

There are more than 1,000 new Medicare enrollees every day in California, yet many physicians are no longer accepting new Medicare patients.

“California desperately needs payment reform to improve access to physicians because Medicare influences all public and private health insurance,” added Dr. Cobb. “Patients are experiencing access to care problems all across the state and H.R. 2 will help alleviate some of that.”

With the new bipartisan agreement between House Speaker John Boehner (R-OH) and Minority Leader Nancy Pelosi (D-CA) on how to fund the SGR fix, CMA is calling on Congress to immediately pass this monumental, fiscally responsible legislative achievement that will lead to meaningful improvements in our health care system.

Meaningful Use Relief

Additional relief for eligible providers participating in the meaningful use program has arrived in two forms – expanded payment adjustment exemptions and extended assistance.

Expanded Exemptions – Providers who are eligible for the Medicare EHR Incentive Program and have been unable to successfully demonstrate meaningful use for either the 2013 or 2014 reporting year due to circumstances beyond their control may apply for a hardship exemption. The deadline to apply is July 1, 2014. An organization whose hardship application is approved would be exempt from payment adjustments which take effect in 2015. CMS is currently accepting applications from both new and returning program participants whose circumstance meets one of the following hardship exemptions:

1.       Lack of infrastructure

2.       New Eligible Professionals

3.       Unforeseen and/or uncontrollable circumstances

4.       Lack of face-to-face interaction

5.       Lack of control over availability of EHR certified technology

6.       2014 EHR Vendor Issues

Visit the CMS Payment Adjustment and Hardship Exemption webpage for downloadable tip sheets that detail the qualifications of each hardship exemption. The webpage also includes a link to the application and further instructions.

Extended Assistance – Eligible professionals may still seek subsidized assistance from CalHIPSO to meet meaningful use in 2014. CalHIPSO is the federally funded regional extension center serving clinicians in all California counties except Orange and LA. CalHIPSO is continuing to provide technical services through December 31, 2014 to both current and new members. However, there is limited availability for new enrollments. Contact CalHIPSO for more information at 510.302.3364 or email organization name, contact info, zip code and NPIs to

Legislation To Repeal SGR Unveiled

The Energy and Commerce Committee Republicans unveiled draft legislation that would repeal the sustainable growth rate (SGR) formula and replace it with a new system for determining Medicare physician payments. Building off a framework released this spring; the legislation would eliminate the SGR and replace it with a modified fee-for-service system with an emphasis on improving quality and outcomes through performance measures, while also providing means for physicians to participate in alternative payment models.

Medicare reimbursement for physicians will be cut by 2 percent on April 1

With no solution on the horizon to the budgetary woes in Congress, physicians should prepare for a 2 percent reduction in reimbursement from the Medicare program beginning on April 1.

The 2 percent Medicare “sequestration” cuts are part of the $1.2 trillion in cuts required by the Sequestration Transparency Act, part of a deal worked out to end last year’s debt-ceiling crisis. Under the act, across-the-board cuts will be triggered if Congress fails to come to an agreement on how to reduce the federal deficit. The cuts are evenly split between defense spending and discretionary domestic spending. Medicaid is exempt from the cuts.

The mandatory Medicare cuts will result in a savings of $11 billion in 2013.

The biggest of the sequestration cuts will hit the Department of Defense, which will lose almost $55 billion. Education will lose 100 percent of the $38 billion in annual grants it gives to states. Total cuts for 2013 will be $109 billion.

Although it is possible that Congress will eventually come to an agreement and reverse some of these cuts, physicians should prepare for the possibility of a 2 percent cut to their Medicare claims.

The California Medical Association (CMA) is vigorously fighting the Medicare cuts. CMA leaders were in Washington, D.C., mid-February urging the California Congressional delegation to stop these cuts. We will keep fighting.

While implementation is scheduled for April 1, 2013, the actual impact may not be felt for several weeks, while Centers for Medicare & Medicaid Services implements the necessary changes.

For more information, see “Sequestration FAQ: How will the cuts affect California physicians?” This FAQ, available in CMA’s online resource library at, answers the most commonly asked questions about the sequestration cuts as they relate to health care. This document will be regularly updated as additional details become available.

Contact: CMA’s reimbursement helpline, (888) 401-5911 or

Coordinated Care Initiative Executive Summary

Passage of the Coordinated Care Initiative (CCI) in July 2012 marks an important step toward transforming California's Medi-Cal (Medicaid) care delivery system to better serve the state’s low-income seniors and persons with disabilities. Building upon many years of stakeholder discussions, the CCI begins the process of integrating delivery of medical, behavioral, and long-term care services and also provides a road map to integrate Medicare and Medi-Cal for people in both programs, called “dual eligible” beneficiaries.

Created through a public process involving stakeholders and health care consumers, the CCI was enacted through SB 1008 (Chapter 33, Statutes of 2012) and SB 1036 (Chapter 45, Statutes of 2012).

 Major Components of the Initiative

  1. Duals Demonstration: A voluntary three-year demonstration program for Medicare and Medi-Cal dual eligible beneficiaries will coordinate medical, behavioral health, long-term institutional, and home- and community-based services through a single health plan. The CCI provides state authority for the demonstration, which is pending federal approval.
  1. Managed Medi-Cal Long-Term Supports and Services (LTSS): All Medi-Cal beneficiaries, including dual eligible beneficiaries, will be required to join a Medi-Cal managed care health plan to receive their Medi-Cal benefits, including LTSS and Medicare wrap-around benefits.

 Location and Timing
The CCI will be implemented in eight counties beginning in 2013. The eight counties are Alameda, Los Angeles, Orange, Riverside, San Bernardino, San Diego, San Mateo, and Santa Clara.

The participating health plans are part of the state’s existing network of Medi-Cal health plans and have experience providing Medicare managed care. Each underwent a rigorous selection process.

Implementation Status

The California Department of Health Care Services (DHCS) is finalizing a Memorandum of Understanding (MOU) with the Centers for Medicare & Medicaid Services (CMS). In fall 2012, the state and federal governments will conduct a comprehensive readiness review of the health plans before signing three-way contracts between the health plans, CMS, and DHCS.

Enrollment will begin no sooner than March 2013. Before any beneficiary is enrolled, the health plans must pass a readiness review process during which the state and federal governments will evaluate each health plan’s major systems to ensure they are prepared to provide required continuity of care, seamless access to medically necessary services, care coordination across LTSS, behavioral health and medical care, and beneficiary protections.

 Participating Population
The state estimates that about 560,000 (Note: this number could go down after capitation rates are released and health plans consider their participation options. ) dual eligible beneficiaries will be eligible for passive enrollment in the eight counties. An estimated one-third of those beneficiaries already are enrolled in managed care for Medi-Cal, Medicare, or both.

Dual eligible beneficiaries and Medi-Cal seniors and persons with disabilities are among California’s highest-need residents. They tend to have many chronic health conditions and need a complex range of medical and social services from many providers. This fragmentation leads to beneficiary confusion, poor care coordination, inappropriate utilization, and unnecessary costs.

Under the CCI, enrolled beneficiaries will have one point of contact for all their covered benefits. They will have one health plan membership card and access to a nurse or social worker whose job is to act as a care coordinator or navigator and help beneficiaries receive the services needed to achieve their personal heath goals and continue living in the setting of their choice. The state is developing care coordination standards that will guide how services are linked.

 Coordinated Care Initiative Goals
By consolidating the responsibility for all of these covered services into a single health plan, the CCI expects to achieve the following goals.

  1. Improve the quality of care for beneficiaries
  1. Maximize the ability of beneficiaries to remain safely in their homes and communities, with appropriate services and supports, in lieu of institutional care.
  1. Coordinate Medi-Cal and Medicare benefits across health care settings and improve continuity of care across acute care, long-term care, behavioral health, and home- and community-based services settings using a person-centered approach.
  1. Promote a system that is both sustainable and person- and family-centered and enables beneficiaries to attain or maintain personal health goals by providing timely access to appropriate, coordinated health care services and community resources, including home- and community-based services and mental health and substance use disorder services.
Financial Alignment Model

Under the CCI, the participating health plans will receive a monthly payment to provide beneficiaries access to all covered, medically necessary services. This is called “capitation.” These bundled payments create strong financial incentives for the health plans to ensure beneficiaries receive necessary preventative care and home- and community-based options to avoid unnecessary admissions to the hospital or nursing home.

 LTSS Integration
Participating health plans will be responsible for administering all Medi-Cal LTSS that historically have been excluded from managed care. LTSS includes skilled nursing facility care, along with the following home- and community-based services: In-Home Supportive Services (IHSS), Community-Based Adult Services (CBAS), Multipurpose Senior Services Program (MSSP), and other services that help beneficiaries stay in their homes and communities, as determined by the health plans.

IHSS will remain an entitlement program. IHSS consumers’ will continue being able to self-direct their care by hiring, firing, and managing their IHSS workers. County social workers will continue determining IHSS hours. The current fair hearing process for IHSS will remain in the initial years of the demonstration.

 Behavioral Health Coordination
Health plans participating in the duals demonstration will provide beneficiaries all mental health and substance use services currently covered by Medicare and Medi-Cal. County-administered specialty mental health services and Drug Medi-Cal substance use treatment services will not be included in the demonstration health plans’ capitation payments. County agencies will continue financing and administering these services, but health plans and county agencies will have written agreements outlining how they will coordinate services.

 Better Care Improves Health and Drives Lower Costs
The CCI is expected to produce greater value for the Medicare and Medi-Cal programs by improving health outcomes and containing costs, primarily through rebalancing service delivery into the home and community and away from expensive institutional settings. Better prevention will keep people healthy. Better care coordination will reduce unnecessary tests and medications. Better chronic disease management will help people avoid unnecessary hospital care.

Significant stakeholder feedback informed the beneficiary protections needed to drive success and quality in the CCI’s design and implementation. The CCI includes comprehensive protections to ensure beneficiary health and safety and high quality care delivery, which includes medical care, LTSS and behavioral health.

Tips for Small Provider Practices to Plan for the ICD-10 Transition

Although the final rule on the proposed ICD-10 deadline change has yet to be published, it is important to continue planning for the transition to ICD-10. The switch to the new code set will affect every aspect of how your organization provides care, but with adequate planning and preparation, you can ensure a smooth transition for your practice.

You should consider the following checklist to help keep your efforts on track with your transition:

  • Educate staff and leadership about ICD-10
    • Appoint an ICD-10 coordination manager and delegate a steering committee  to manage the transition 
    • Train staff on changes in documentation requirements from health plans and how this will affect work flow 
  • Perform an impact assessment
    • Examine existing uses of ICD-9 codes in order determine aspects of work flow and business practices that ICD-10 will potentially change. Be sure to evaluate planned and ongoing projects as well
    • Create a list of staff members who need ICD-10 resources and training, such as billing and coding staff, clinicians, management, and IT staff
  • Plan a realistic and comprehensive budget
    • Estimate a budget that includes costs such as software, hardware, staff training, and any initial change in patient volume
  • Coordinate with external partners
    • Contact system vendors, clearinghouses, and billing services to assess their readiness and evaluate current contracts
    • Ask your vendors how they will support you in the transition to ICD-10 and request  a timeline and cost estimate
    • Analyze existing health plan trading partner agreements
  • Get ready for testing
    • Request a testing plan to schedule from your vendor
    • Conduct internal testing within your clinical practice as well external testing with payers and other external business partners after you have completed the planning stages 

Keep Up to Date on ICD-10.
Please visit the ICD-10 website for the latest news and resources to help you prepare!

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