PRACTICE NEWS AND RESOURCES

Free to SJMS/CMA Members!

The Office Managers Forum empowers physicians and their medical staff with valuable tools via expert led educations sessions from industry professionals who are committed to delivering quality healthcare.

For the time being, we will be offering Zoom Meetings until we can get back to meeting in person. This monthly forum is normally held on the second Wednesday of each month. Registration is required!

If you don’t receive a monthly invitation via E-Mail, please email Jessica@sjcms.org for the Zoom call info!

October 13th, 2021: TBD

November 10th , 2021: 11:30AM-1PM The Modern Workforce Revisited – 5 Ways to Attract and Retain the Next Generation of Workers

Presented by: Jeff Gilbert and Chad Sublet – Verve IT

In our previous presentation, Jeff and Chad advocated for a new way of thinking about the Workplace in order to attract and retain the growing Millennial demographic. Now, here in 2021, more than 50% of the workforce is comprised of Millennials - and not only will this number continue to increase, but Generation Z is hot their heels.

With the impact of COVID, and businesses globally rethinking their work-from-home policies, the Modern Workplace is now no longer a luxury - it is an essential business strategy to compete for the best talent in this new, modern era.

Join us as we revisit our original presentation and update you on the latest trends that will help you continue to attract and retain the next generation of workers.

Jeff Gilbert, CEO– Jeff has been in the Information Technology industry for 20 years, and has served in virtually all aspects of the IT world, getting his start in basic IT work, progressing through software development and architecture, and finally to IT Management. Jeff’s career has led him to provide services for some of the world’s largest firms, including global project management firms, and top 5 national defense firms. Jeff lives in Stockton with his wife Christina and their 4 sons.

Chad Sublet, Partner – Chad’s background includes 20+ years of customer service and sales. Starting his technical career with electronics repair in the USAF Minute Man program and transitioning those skills to satellite and weapons repair in the civilian world. Eventually growing his skillset to sales, and becoming a partner at Verve in 2008. Chad now has responsibility for the Verve Sales & Account Management team. Chad lives in Stockton with his wife Madeline and their 2 children.

December 8th, 2021: 11:00AM to 1:00PM “Medicare Changes: 2022 and Beyond”

This 60-minute virtual (online) training provides your practice with updates on Policy, Payment and Quality Provisions for Medicare under the Physician Fee Schedule (PFS) for CY 2022 and beyond.

Subjects highlighted in this workshop:

• Telehealth during COVID- PHE • Evaluation and Management (E/M) Visits • Quality Payment Program (MACRA) Year 6 • Compliance with the MAC • Other Medicare Part B issues

Your billing staff will walk away with the resources to decrease denials and maximize reimbursement.

Cheryl Bradley is an Associate Director in CMA’s Center for Economic Services. She has over 25 years’ experience in the Medicare Program and has held a variety of responsibilities including

Education and Training Specialist, Medical Review Analyst, and has worked with providers in virtually all specialties across all the CA Medicare contractors. Cheryl is a known educator speaking at conferences, state associations, and for numerous organizations. She provides problem solving assistance to CMA member physicians on a number of Medicare issues. She is great at using humor to help providers navigate this difficult healthcare program.

CMA PRACTICE RESOURCES

UHC DELAYS DESIGNATED DIAGNOSTIC PROVIDER PROGRAM IN CA UNTIL JAN. 1, 2022

United Healthcare (UHC) has delayed implementation of its Designated Diagnostic Provider (DDP) program for laboratory services in California. Previously scheduled to begin July 1, 2021, the DDP program is now tentatively scheduled to be implemented on January 1, 2022, pending regulatory approval. The program will create a tiered network for laboratory services for its fully insured commercial lines of business and will limit outpatient laboratory service coverage to only Designated Diagnostic Provider labs, which are freestanding or hospital outpatient labs that have met certain quality and efficiency requirements.

The delay follows questions raised by the California Medical Association (CMA) and other stakeholders regarding implementation of the DDP program, including concerns with how physicians and patients will identify DDP labs in the UHC provider directory, confusion identifying patients with coverage limited to DDP laboratories, potential concerns with timely access to lab services for UHC enrollees and increased patient out-of-pocket costs when they mistakenly receive services from an out-ofnetwork lab provider.

Citing the need to reduce outpatient diagnostic laboratory costs, UHC had planned to implement DDP as part of its new patient benefit designs for 2021, pending state regulatory approval. Originally, the DDP program would have required patients under these new benefit designs to only access DDPs for outpatient diagnostic lab services. Patients who utilized any other provider would have had services denied as non-covered and could be held financially liable for the charges. UHC has, however, recently altered the program to now cover patients for outpatient diagnostic lab services at a lower cost share when delivered by a DDP with patients paying a greater cost share for care rendered by non-DDPs.

Once implemented, the DDP benefit designs will not apply to lab services rendered as part of inpatient admissions, emergency room visits or outpatient surgery pre-operation testing that is billed as part of a global surgical package.

UHC plans to expand the DDP benefit designs and limited provider network to major radiology services (MR, CT, PET/Nuclear Medicine) beginning January 1, 2022. However, UHC has advised that the delay for laboratory services will likely impact the implementation timeline for radiology services as well.

Providers with questions or concerns regarding the DDP program can email United Healthcare at ddp_lab@uhc.com. For more information on the DDP program, see UHC’s Frequency Asked Questions or visit uhcprovider.com .

DID YOU KNOW? PHYSICIANS CAN HELP PATIENTS APPEAL MEDICAL NECESSITY DENIALS

Both the California Department of Managed Health Care (DMHC) and the California Department of Insurance (CDI) have independent medical review (IMR) processes through which patients can request an external medical review of any health plan or insurer decision to deny, modify or delay treatment based on a lack of medical necessity or investigational or experimental denials.

Under California law, all patients enrolled in fully insured commercial products regulated by DMHC or CDI have the right to appeal these denials through the regulator’s IMR process.

The goal of the legislature in mandating the availability of this formal IMR process was to ensure that appropriate and equitable medical necessity decisions are made and to increase public confidence in the managed care system.

Both the DMHC and CDI have established IMR processes that are accessible on the regulator websites.

According to the 2020 DMHC Annual Report, 68% of consumers who submitted an IMR request received the service or treatment they requested. CDI’s Interactive Independent Medical Review Statistics also show that 53% of IMRs filed through CDI were decided in favor of the patient.

During an IMR, independent physicians that do not work for the health plan will examine the case to see if the denial was appropriate or if the enrollee should receive the requested service or treatment. If it is determined that the health plan/insurer’s denial was not appropriate, the plan/insurer must cover the requested service or treatment. Before filing for an IMR, patients must first file a grievance with their plan/insurer. However, if the patient does not agree with the health plan/insurer's response or the payor takes more than 30 days to fix the problem, the patient can file for an IMR through the DMHC Help Center or through CDI, depending on which entity regulates the patient’s insurer. Typically, DMHC regulates all HMOs as well as the Blue Shield and Anthem Blue Cross PPOs, while CDI regulates the remaining PPO products.

It’s also important to know that physicians can assist their patients in filing for IMR or can file on the patient’s behalf. Patients who wish to designate a physician or another person to file on their behalf must complete and sign the required DMHC Authorized Assistant Form or for CDI regulated products must sign the Designation of IMR Agent (last page of the IMR form).

IMR requests must be made within six months unless the regulator approves an extension due to special circumstances. Applying for an IMR is free.

For more information about how physicians can assist patients in seeking an IMR, see California Medical Association health law library document #7155, “Independent External Medical Review.”