Payment Policy
Here is an update on the status of Anthem Blue Cross’s transition to a $75 per diem rate and expansion of their provider network. CPTA, OTAC and the CSHA 's direct communication with Anthem Blue Cross has been limited. We have been unsuccessful in scheduling face to face meetings with them. However we have made contact with the DMHC. The most recent discussion revealed the following:
The Department of Managed Health Care (DMHC) has determined that at this time Anthem Blue Cross of California is not in violation of the Knox-Keene Health Care Service Plan Act of 1975.
Based on the information Anthem provided to the DMHC to date, the DMHC has no evidence that demonstrates that Anthem’s PT/OT/SLP network does not provide available and accessible services to its PPO enrollees.
The DMHC will continue its investigation of the Anthem network and will specifically look at the specialty areas of rehabilitative care.
President Obama signed H.R. 4691 into law. This bill re-instates the therapy cap exceptions process until December 31, 2010...
On June 25, 2010, President Obama signed into law the “Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010”. This law extends through November 30, 2010, the 2.2 percent update to the MPFS. The law is retroactive to June 1, 2010.
Linda Berezny, PT CPTA Payment Policy Committee Member
The Prospective Payment System [PPS] for Skilled Nursing Facilities [SNFs] is a result of the Balanced Budget Act of 1997. It replaced a cost-based or fee for service reimbursement system. There are currently discussions taking place that may, if passed into law, refine the system for future Medicare savings, will add more patient categories, and re-vamp the current assessment used for PPS reimbursement determination. Click here to view the full article.
On June 25, 2010, President Obama signed into law the "Preservation of Access to Care for Medicare Beneficiaries and Pension Relief Act of 2010." This law establishes a 2.2 percent increase to the Medicare Physician Fee Schedule (MPFS) payment rates retroactive from June 1 through November 30, 2010. The Centers for Medicare & Medicaid Services (CMS) has directed Medicare contractors to discontinue processing claims and to temporarily hold all claims for services rendered June 1, 2010 and later until the new 2.2 percent increase update is loaded into the Medicare contractors' claims processing system. Palmetto GBA expects to begin processing claims at the new rates no later than July 1, 2010. Claims for services rendered prior to June 1, 2010 will continue to be processed and paid at the new rates.
Claims containing June 2010 dates of service, which have been paid at the reduced rate rates will be reprocessed as soon as possible. Claims containing June dates of service that were submitted with charges greater than or equal to the new 2.2 percent update rates will be automatically reprocessed. Providers who submitted claims containing June dates of service with charges less than the 2.2 percent update amount will need to contact Palmetto GBA to request an adjustment. Submitted charges on claims cannot be altered without a request from the provider.
Providers should not resubmit claims to Palmetto GBA because they will be denied as a duplicate claim...
To participate in the 2010 PQRI, individual eligible professionals may choose to report information on individual PQRI quality measures or measures groups to CMS on their Medicare Part B claims...
Effective 1/1/2010, OptumHealth/ACN will cease management of Blue Shield of California physical therapy clinical utilization program. Providers of therapy services will no longer need to submit patient notification forms to OptumHealth for Blue Shield enrollees...
The Division of Workers' Compensation released a new form for reporting utilization review complaints...
CPTA has compiled a comprehensive list of resources to help our members with all their payment policy questions.
Expert resources are available to assist CPTA members in the following areas: Acute Hospital; Rehab Hospital; Long Term Care/SNF; Home Health; In-Patient Part A; Outpatient Part B; CARF/JACHO; California Workers’ Compensation; Federal Department of Labor; Medi-Cal; CCS; Regional Centers; Commercial/Third Party Payor.
For more information on payment issues, please contact Tameka Island, Executive Associate, Professional Affairs at the CPTA Office, (916) 929-2782 or by email at tisland@ccapta.org.
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