Budget Deal Impact on Medi-Cal Provider Rates and Claw Back

 


Last week the Governor held a news conference with Democratic leadership announcing the budget deal. There is nothing in the agreement regarding the Medi-Cal provider rate reductions or the claw back for radiology payments made between 2012-2014. The Legislature's version of the budget would have eliminated 5% of the 10% provider rate cut and 5% of the claw back in April of 2016. The only action regarding rates in the budget agreement was to eliminate the 10% cut for dental services. The radiology claw back is for payments that exceeded 80% of the Medicare allowable for the same service. That limit was supposed to have been implemented in 2011 but did not get completed until November 2014. DHCS decided to not apply the limit for 2010-2012 based upon potential impact on access. This only applies to fee for service Medi-Cal.

 

The Governor did announce that there would be were two special sessions of the Legislature; one on infrastructure and the other on the health care delivery system. The latter would focus on a bill to enact the Managed Care Organization (MCO) Tax to provide permanent funding for Medi-Cal including provider rate increases "that will increase access to services". There has been an MCO tax on the premiums paid for Medi-Cal managed care plans but recent federal regulations require that the tax be applied to all plan premiums.

 

The special session began on June 19th and will run concurrently with the regular session. The Governor wants to have this discussion outside of the budget process, which means the MCO money is what is available for any changes in provider rates. CRS will continue to advocate for relief from both the provider rate reductions and the claw back. This is not good news in terms of short term relief but the reality of the Legislature's solution was that it was insufficient since only provided partial relief for a few months. Further action would have been required in the next budget cycle to provide greater relief.

 



 AB 533 on Out of Network Billing - Hearing Delayed Until 7/15/15

 

 

Last week we asked that you reach out to members of the Senate Health Committee indicating our opposition to AB 533 (Bonta) on out of network billing and essentially a ban on balance billing. The bill was set to be heard on 7/1 but was pulled from the agenda and reset for 7/15. There are also amendments that are under discussion and we will communicate those changes. If you did send an email or make calls we appreciate your effort in doing so and will update you soon on the changes and whether our opposition has been removed.

 

 


 Bill to Expand NP Scope of Practice Fails in Assembly Committee

 

 

SB 323 (Hernandez) that would have expanded the scope of practice for advanced level nurse practitioners failed passage in the Assembly Business and Professions Committee. It had passed the Senate as had a previous iteration two years ago that also languished in the Assembly. AB 323 was amended in Committee to apply the existing anti-kickback and self referral laws to NPs and there was an effort to also apply the corporate practice of medicine bar to NPs. That would have meant that most hospitals that currently employ NPs would not have been able to do so. That amendment was resisted by the author and supporters like the Ca. Hospital Association. The CMA, the major opponent to SB 323, advocated for its inclusion to ensure that both physicians and NP'S operated under the same laws.

 

The CRS sought and obtained an amendment previously to the bill that clarified that an NP would not interpret diagnostic studies, like imaging, but could incorporate the results of studies in their treatment of a patient. SB 323 did obtain reconsideration meaning the bill could be heard again, but it's likely that it will be a two year bill and not heard again until 2016.

 

 


 Medi-Cal Denials of Services

if Ordering/Referring Physician is not Enrolled

 

 

Medi-Cal is required to only reimburse for services that are ordered by a physician or other provider that is enrolled in Medi-Cal or Medicare. It is expected that in the very near future that any claim that contains a physician who is either not enrolled in the Medi-Cal program or does not have a Type 1 (Individual) NPI will be denied. DHCS indicates that for the last several months they have been indicating on provider RADs any claim referred by a physician or provider that does not meet that requirement. Those claims are not yet being denied but it is being used as educational tool for billing providers. Here is the recent notice posted on the DHCS website. We expect that the edit will be activated in the near future. 

 

 

ACA Billing and Enrollment Requirements for ORP Providers

June 25, 2015

 

Based on the Affordable Care Act (ACA) of 2010, providers are now required to list the National Provider Identifier (NPI) and name of the provider who ordered, referred or prescribed the goods or services being billed. In addition, all ordering, referring or prescribing (ORP) providers must be enrolled as participating providers in Medicare or Medi-Cal, with a Type 1 (individual) NPI, even if these providers do not send claims to Medi-Cal for the services they provide.

 

If the ORP provider identified on the claim is not enrolled in Medi-Cal or Medicare, claims for reimbursement of the goods or services provided in filling the order, prescription or referral from the ORP provider will not be paid.

 

Providers can find more information on the Provider Enrollment Division page of the Department of Health Care Services website.

 

 


CRS Annual Meeting 
October 2 - 4, 2015 
Newport Beach, CA
 

 
Please plan on attending the meeting this year.  You can link to the program here.  We have tried to provide a series of presentations on emerging issues for radiology including new payment models, the growth of the Ca. Exchange plans and next steps, and the evolution of mid level practitioners and the impact on ordering of services.