Payers & Providers California Edition – Issue of July 19, 2012

7/31/2019 Payers & Providers California Edition Issue of July 19, 2012

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Calendar

19 July 2012

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California Edition

The Department of Managed Health Care isengaged in another battle with Anthem BlueCross of California, ordering the insurerearlier this week to refund hundreds of claims

to providers it contended were improperlyrecouped.According to the DMHC, Anthem was

attempting to recoup claims more than a yearold, a violation of California law unless fraudor misrepresentation is proven. The agencycontended that Anthem between 2008 and2011 attempted to recoup millions of dollarsworth of claims that were at least a year oldwithout making such allegations.

Healthcare providers should not faceunexpected demands for reimbursement ofmedical claims they believe wereappropriately paid years ago, said DMHC

Director Brent A. Barnhart. Anthemsrecoupment practices violate California lawand are unfair to providers who are acting ingood faith.

Many of the claims appear to beregarding womens reproductive health issues,according to a statement from Anthemofcials. A DMHC spokesperson did notrespond to an e-mail and telephone callseeking comment.

According to the DMHCs July 16 ceaseand desist order, Anthem had attempted to

recoup 548 claims from 13 unidentiedproviders that were more than one year old. Inits correspondence, the health plan only askedfor specic dollar amounts and did not

mention patient names or dates of service.Anthem had suggested that the disputes werethe result of upcoding or miscoding ratherthan fraud or misrepresentation.

Anthem disputed the allegation, sayinginstead providers had double-billed.

Anthem Blue Cross believes medicalproviders should be compensated for servicesprovided, but should not receive paymenttwice for the same procedure. Consistent withAMA guidelines, Anthem Blue Cross hassought reimbursement for these overpaymentswhere medical providers have led for andreceived over payments due to double billing,

said spokesperson Darrel Ng. Some providerare submitting it as both a pap smear and as awell-woman visit. Essentially, they are gettingdouble paid for the same work. The vastmajority of providers nationwide are codingthis correctly, and (a) very small minority aredouble billing. Thats who were going after.

Ng said that Anthem was considering itsoptions in responding to the DMHC order,which it could ght in court.

Alleged double-billing has become a

July 19-21

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Payers & Providers Page 2

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In Brief

Healthcare PriceSpikes Remain Low

New data from a Michigan think tank

has concluded price spikes in thehealthcare sector have slowed to arate not seen in more than a decade.

According to Ann Arbor-basedAltarum Health, prices were up just2% between May 2011 and May2012, the slowest growth since

January 1999. Healthcare spendingwas also taking a slow growthapproach, increasing 3.8% betweenMay 2011 and May 2012, and onpace for about $2.8 trillion this year.

Spending has experienced anaverage annual increase of about3.9% since the middle of 2011,according to Altarum.

Our analysis continues to show

stable health spending growthhovering around the 4% mark, andthis three-and-a-half year trend isentirely unprecedented, said CharlesRoehrig, director of the AltarumCenter for Sustainable HealthSpending. As a result, healthspending as a share of GDP has heldsteady at about 18% over this sameperiod and, were it not fordisappointing GDP growth, couldactually be falling.

Spending has increased about11% since the Great Recession beganin late 2007, compared to a 7.3%increase in non-healthcare prices.

Altarum could not give aspecic reason for the slowing inhealthcare prices, which routinelyoutstripped ination by two or threetimes in years prior to the GreatRecession.

Prior to the economic turmoil,the annual price growth was about10.6% per year, according toAltarum.

Hospitals represented thebiggest chunk of healthcare spendingin May, about $890 billion on an

Continued on Page 3

NEWS

growing focus of auditors for health plans,industry experts say, although some chargescan be the result of poor data management by

the provider or contractors that may processclaims for health plans. Blue Cross Blue Shieldof North Carolina which is not afliatedwith Anthem has been focused on radiologyproviders billing for separate images taken

Anthem (Continued from Page One)

during the same procedure, claiming it hasresulted in $16 million worth of overcharge

Meanwhile, Anthem Blue Cross remain

by far the biggest target of DMHCsenforcement actions and nes. The agency levied 744 penalties against Anthem to datemore than 40% of all such actions takenagainst a total of more than 90 entities.

PAMF, Cigna Launch New ACOFirst in California For Health Insurance Giant

Cigna, the Connecticut-based insurance giant,has launched dozens of accountable careorganizations throughout the United States.Just this week, it nally announced its rstACO in California.

Cigna will join forces with the Palo AltoMedical Foundation in Mountain View andthe afliated Mills-Peninsula Medical Groupto launch an ACO that will provide care forabout 21,000 Cigna lives about 3% ofPAMFs entire patient base of 750,000. Bothgroups are afliated with Northern Californiahospital powerhouse Sutter Health.

According to Sutter Vice President Cecilia

Montalvo, the lives represent the number ofCigna PPO enrollees who have beendedicated to receiving care through the twomedical groups.

A joint statement issued by PAMF andCigna said few patients will notice analteration in the care they receive from theirproviders. Most of the ACOs efforts will focuson stabilizing the costs associated withchronic conditions such as heart disease anddiabetes. Enrollees will also be offeredlifestyle management programs for tobaccocessation, weight loss and stress management.

PAMF will be under considerable

pressure to rein in costs, based primarily on

quality improvement. The medical group andits providers will have to follow 100 evidencebased procedures chosen by Cigna to improvthe quality of healthcare delivery, Montalvosaid. Only if it meets certain thresholds inthose categories will it receive incentivepayments assuming there are cost savings aall.

We believe this arrangement offers awonderful opportunity for us to improvehealthcare quality, lower medical costs andhelp our patients lead healthier and moreproductive lives, said PAMF chief executiveofcer Richard Slavin, M.D.

PAMF shares our vision for a patient-centered healthcare system that emphasizesprevention and primary care and rewardsphysicians for care quality and healthoutcomes, said Peter B. Welch, Cignasdivision president in northern California. Webelieve that a system thats focused on valuerather than volume of care offers the best patto improved health and lower medical costs,which is good for individuals, families,employers and doctors.

The ACO launched on July 1, and willremain in place indenitely, ofcials said. It ithe 32nd ACO Cigna has launched in 16 statsince 2008.

MEET YOUR FELLOW READERS

Need to promote a conference? Your brand? Payers &Provider!se-mail list for all editions is available for yourmarketing needs. Reach out to more than 12,000healthcare professionals who read our publications. CaClaire Thayer at (877) 248-2360, ext. 3 or e-mail her [email protected].


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Page 3Payers & Providers

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In Brief

annualized rate, or 32% of allexpenditures. Physician and clinicalservices represented about 19% oftotal spending, or $536 billion.

Cal FreshWorks Fund

Provides $105,000In Grants

The California FreshWorks Fundhas issued $105,000 in grants tocreate better access to healthierfoods for low-income families inSouthern California and the BayArea.

The grants were awarded tothe Community DevelopmentFoundation of Los Angeles County;the Heritage Education Group inCompton; and the MandelaMarketplace in Oakland.

The first two grantees will usethe money in part to start up newfarmers markets in their serviceareas.

The Mandela Marketplace willexplore the feasibility of expandinga cooperative market in theOakland area.

Many studies havedemonstrated that low-incomeareas of California are fooddeserts, full of convenience storiesand fast food outlets, but providingfew markets with fresh produce.

More than 1 millionCalifornia residents need to driveover 20 minutes from their homesto buy fresh produce, and mostdon't or can't do it," said ScottSporte, Chief Lending Officer atNCB Capital Impact, whichadministers the fund. Theseinvestments build on innovativehealthy eating initiatives and willhelp more families shop closer tohome for foods that can help themlive healthier, happier lives.

The fund, seeded with moneyfrom Kaiser Permanente and theCalifornia Endowment, providesgrants and loans to businesses thatencourage healthier eating andlifestyles.

NEWS

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Big Variations In Surgical PricesReport Details Huge Differences by Hospital

Anew studyby a non-prot watchdog groupconcludes that prices for the same surgicalprocedure vary dramatically acrossCalifornia, with many areas in the Bay Areaand Sacramento among the most expensive.

According to the study, commissioned bythe CalPIRG Education Fund and conductedby the Santa Barbara-based Frontier Group,hospital prices varied by as much as 270%,depending on the region.

Alameda County was the most expensivearea of the state for hospital care, accordingto the study, with charges about 162% abovethe statewide median. Fresno County was theleast expensive, with charges at around 60%of the median.

The Los Angeles and Salinas areas wereclosest to the median, with the former justabove and the latter just below.

The study did not give specicexplanations for the cost variation, althoughit suggested that cost-of-living in someregions may dictate some but not much ofthe differences, as well as whether thehospital is for-prot or not-for-prot (for-prots generally charge more, itconcluded).

In one example, a knee replacementsurgery would cost $42,213 at AdventistMedical Center in Hanford. At WashingtonHospital in Alameda County, the sameprocedure costs $164,366.

For a Cesarean section, a commonplaceand relatively simple procedure, SetonMedical Center in San Mateo County charges$54,866. At Clovis Community MedicalCenter in Fresno County, the same procedurecosts $12,940.

According to this data, a pregnantwoman in the Bay Area could take a private

jet to Fresno, stay at the nicest hotel in the cand still save thousands of dollars on herbirth, said Daniela Uribe, a CalPIRGEducation Fund fellow.

However, dramatic price variations coualso occur in the same region. In low-pricedOrange County, a C-section at Hoag MemorHospital Presbyterian results in a $12,200charge, versus $31,000 at SaddlebackMemorial Medical Center, according to thereport.

The study used hospital chargemastersobtained from the Ofce of Statewide HealtPlanning and Development.

However, such chargemasters often reethe highest price for a procedure, similar tothe rack rate charged by a hotel for acustomer who has obtained no discounts.Patients with insurance often pay far less outpocket for such care, and the insurersthemselves usually obtain discounts of 50% more. Only 12% of Californians pay for theicare out of pocket, according to the reportsown ndings.

Such charges also do not account the feof an anesthesiologist and other specialtyphysicians who may assist in performing theprocedure.

The report recommended greater pricetransparency for consumers in order to makemore informed decisions about choosinghospitals, and the uniform use of bestpractices in order to keep quality up and cosdown.

Overcharges are unacceptable for aservice as important as healthcare, Uribesaid. Consumers, whether its on their own through higher insurance premiums, shouldnbe paying 250% more for the exact samesurgery at different hospitals.
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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

HEALTH PLAN/HOSPITAL CONTRACTING CONSULTANT(flexible hours)

A dynamic and growing medical group in the Los AngelesCounty area is currently seeking a highly experienced con-tracting consultant for the purpose of leading and success-fully negotiating and renegotiating health plan and hospitalcontracts. The ideal candidate will have an understandingof all product lines within the managed care industry, bewell-versed in contractual language, excel at maintainingpositive working relationships internally and externally, anddemonstrate an understanding of legal, financial and opera-tional processes that meet company objectives. Flexiblehours and telecommuting are available.

If interested, please email your cover letterand resume to:[email protected]

Casa Colina Centers for Rehabilitation, a nationally recognizeleader in the field of medical rehabilitation located in Pomona, iseeking to fill the vital role of Controller to oversee the Financand Accounting functions for the entire rehabilitation continuumwith a total bed complement of 178 beds, and consisting of hospital, brain injury program, 3 long term care facilities, an AduDay Health Center and outpatient childrens program.

The selected candidate will be responsible for all financial, payroand A/P activities. Oversees internal controls to ensure revenucycle effectiveness, expenditure management and safeguardinof assets. Prepares financial statements in a timely, accuratand efficient manner. Supervises all accounting and payroll stafResponsible for tax returns and regulatory filings. Requirementinclude a Bachelors degree in Accounting or Business relatefield, two (2) years of supervisory experience, prior hospitalhealthcare accounting experience, and a working knowledge oaccounting software programs. CPA background is strongly preferred. Excellent work ethic and motivation required.

Competitive compensation and excellent benefit optionsavailable. To apply, visit us at www.casacolina.org/jobs.

Principals only at this time.

CONTROLLER/

DIRECTOR OF FINANCE

It costs up to $27,000 to fill a healthcare job*

will do it for a lot less.

Employment listings begin at just $1.65 a word

Call (877) 248-2360, ext. 2

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*New England Journal of Medicine, 2004.


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Payers & Providers California Edition – Issue of July 19, 2012

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