Payers & Providers California Edition – Issue of March 15, 2012

8/2/2019 Payers & Providers California Edition Issue of March 15, 2012

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Calendar

15 March 2012

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the details of your event, or call(877) 248-2360, ext. 3. It will be

published in the Calendar section,space permitting.

California Edition

Californias provider and payer communitieslined up this week against a proposed ballotmeasure for the November election that wouldprovide the California Insurance

Commissioner new powers to regulate healthinsurance premiums.The California Medical Association,

California Hospital Association and CaliforniaAssociation of Physician Groups have bandedtogether to create an organization calledCalifornians Against Higher Health CareCosts.

We are condent when voters nd outabout the many aws in this proposal, andhow it will hurt their own healthcare, they willoppose it, said Don Crane, CAPGs chiefexecutive ofcer.

Although the initial announcement of the

coalition prominently featured the providerorganizations, its website,www.stophighercosts.com, stated that most ofits funding is coming from the states fourmajor insurers: Anthem Blue Cross, KaiserFoundation Health Plan, Blue Shield ofCalifornia and Health Net. The site itself isoperated by a Studio City public relations rm,Fiona Hutton & Associates, whose clientsinclude the California Association of HealthPlans.

Their opponent in this instance is alongtime insurance industry nemesis:

Consumer Watchdog, the Santa Monica-baseadvocacy group that won a landmark victoryin the 1980s passing a ballot proposition toregulate automobile insurance premiums.

Consumer Watchdog is operating its ownwebsite, www.justifyrates.org, to help gatherdonations and the 550,000 signatures requireby the end of May to qualify the initiative.

Should it qualify and be approved byvoters, it would allow the InsuranceCommissioner to have the nal say onproposed rate hikes. Currently, theDepartment of Insurance can only providesuggestions. It would also cap administrativeexpenses and outlaw underwriting practicesthat take into account an applicants credithistory or prior insurance coverage.

Opponents are hiding behind the

medical establishment but it's the insurancecompanies footing the bill, said CarmenBalber, who directs Consumer WatchdogsWashington, D.C. operations.

The ballot initiatives language is similar tAB 52, which died in the Legislature last yearafter failing to garner enough support in theSenate.

Payers & Providers reported last year thatState Sen. Ed Hernandez, D-West Covina andchair of the Senate Health Committee,receives about $69,000 a year in rentalincome from Kaiser Permanente.

March 19


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Payers & Providers Page 2

Top Placement...Bottomless Potential

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In Brief

State To Share In $75Million CMS Grant

California was one of 11 states thatwill share in a $75 million grant from

the Centers for Medicare andMedicaid Services to improvepsychiatric care.

The money will power ademonstration project where privatepsychiatric facilities can receiveMedicaid reimbursement for services.Historically, such facilities have notbeen eligible for Medicaidparticipation. Medicare does pay forsome forms of inpatient psychiatriccare.

This new demonstration willhelp ensure patients receiveappropriate, high quality care whenthey need it most and savemoney,said CMS Acting Administrator

Marilyn Tavenner.The demonstration project willlast three years.

Health NetRepurchases More

Stock

Health Net has given its sharerepurchase program a huge boost,more than doubling a prior spree ofbuying its own stock.

The board of directors of theWoodland Hills-based insurer

authorized an additional $323.7million for its stock repurchaseprogram. Thats on top of a $300million repurchase programauthorized last year.

The buyback program has hadsome effect: Health Net shares are upnearly 20% over the past year, eventhough recent earnings reports havebeen at.

To date, Health Net hadrepurchased all but $76.3 million of

Continued on Page 3

NEWS

The Department of Managed Health Care hastaken rare legal action against an individualphysician for her persistent balance billing ofpatients.

South Pasadena plastic surgeon JeannetteY. Martello, M.D., 50, is also facing thepotential revocation of her professional licenseby the Medical Board of California.

The DMHC issued a cease and desistorder against Martello in March 2011 after atleast two of her patients led complaints withthe agency.

According to documents obtained byPayers & Providers, Martello in 2009 and

2010 performed plastic surgery in SouthernCalifornia hospital emergency rooms to repairfacial cuts on two individuals separatelyinsured by Anthem Blue Cross of Californiaand Cigna Healthcare of California. In bothinstances, Martello insisted the parties including the parents of a minor child whowas receiving her care sign waivers requiringthem to reimburse her.

After submitting and receiving paymentsfrom Anthem and Cigna at discounted rates,Martello billed the patients for the remainderof the non-discounted charges, according tothe DMHC. She collected $1,040.60 from the

childs parents, and sought $8,818.49 from theother patient. She led suit against both theadult patient and the child patients parentslast year.

Under California law, patients enrolled inmanaged care plans are not required to payadditional fees to non-network providers otherthan routine co-payments and deductibles.The providers may seek additional paymentfrom the health plan.

Dr. Martellos request that her patientswaive theirrights is unconscionable, invalidand unenforceable, the DMHC said in its

cease and desist order, which Martello did contest.

Although the DMHC has acted againstmedical providers who engage in balancebilling, most such actions have been againsmedical groups or other large-scaleorganizations.

Moreover, DMHC records indicated thMartello ignored the cease and desist orderand continued to balance bill patients andthreaten legal action or sue if they didnt pa

This prompted the agency to sue her laJuly in Los Angeles County Superior Court.The lawsuit, which is still pending, seeks

disgorgement of the monies she has collectdismissal of all the lawsuits against Martellopatients, and a $2,500 per day ne of Marteand her medical practice for each violationthe states Knox-Keene Act, which regulatesCalifornias managed care health plans.

The month after the DMHC led suit, tCalifornia Medical Board moved to revokeMartellos license, alleging gross negligenceconnection with a breast augmentationprocedure she performed in 2007.

According to the Medical Board, Marteimplanted a breast size larger than wasmedically safe, resulting in a compromised

blood supply to both breasts. In a follow-upprocedure, she removed only one of theimplants.

The action to revoke Martellos licenseremains pending.

Martellos state of affairs is a far cry frodecade ago, when pharmacy retail giantWalgreens sold a $49 wrinkle cream underher name and she made appearances as atelevision commentator.

Attempts to reach Martello wereunsuccessful. Two phone numbers listed asbelonging to her practice were disconnecte

Doctor Engaged In Balanced BillingSurgeon Ignored Order From DMHC, Sued Patient

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Page 3Payers & Providers

Longer ALOS!*

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*For our ads, not your hospital

In Brief

its prior repurchase authorization,clearing the way to buy back as muchas $400 million in additional stock. Ifexercised in total, Health Net wouldeventually buy back more than $623million of its shares.

Study Focuses On FixingSafety Net

A report released last week by theCommonwealth Fund Commission ona High Performance Health Systemoffers recommendations to sustain andsupport safety net hospitals facingchanges under health reform.

Deborah Bachrach andcolleagues at Manatt Health Solutionscreated the report with theanticipation that low Medicaidpayments, an inux of Medicaidpatients and a reduction in

disproportionate share funding underthe Affordable Care Act may bringchallenges to the already-strappedinstitutions.

Medicaid is currently the largestpayer at safety net hospitals,according to the report. In 2014, thenumber of Medicaid patients willincrease an estimated 17 million ofthose currently uninsured will becomeMedicaid recipients.

The report, Toward a HighPerformance Health Care System forVulnerable Populations: Funding forSafety Net Hospitals, offers ways toreward performance at and targetpublic dollars toward safety net

hospitals.One of the commissionsrecommendations is to increaseMedicaid rates to safety net hospitalsthat meet quality targets and deliveraccessible, reasonably priced care.

While targeting enhancedMedicaid payments to hospitals basedon their safety net status is far fromideal, the report said, they docontend that tying payments toperformance and improvementtargets, would offer a means toaddress quality and access concerns ata time when state Medicaid rates areotherwise low and state resourceslimited.

document which the CalOptima managemeteam has yet to receive two months after itwas leaked. No nal report has been releasto the public or the CalOptima staff, andthe Board of Directors has issued no ofciastatement regarding my performance during

the timeframe covered by this and the earliePayers & Providers story. Furthermore, Iam condent that if the report were correctstating that CalOptima or its members wereat any risk, the Board of Directors would hataken immediate action to address theissue including informing me and requiringthat I implement remedies. No suchcommunications have occurred.

These allegations that have beenmade against our organization and our Boahave had a detrimental impact on our staffmorale and our reputation in the communitWorse, the most recent round of allegations

may jeopardize the granting of the $9.3million MSC grant that was designed to helimprove the delivery of health care to theOrange County residents. Those who wouldbe hurt most by this are Orange County'spoor, who are in the most desperate need ohealthcare access.

In order to correct the record for posterity, Iam by this letter asking Payers & Providers tprominently append this letter in its entiretythe February 17, 2012 article.

Richard Chambers

Chief Executive OfcerCalOptima

Payers & Providers Responds:

Payers & Providers made clear in its reportinthat Mr. Kacic acted separately in his roles athe chairman of the Irvine Health Foundatioand as co-chairman of the Managed SystemCare in an effort to obtain the CMMI grant aintergovernmental transfers.

The CMMI grant documentation also madeclear that the IGTs would be used to provid

forms of care to either existing CalOptimaenrollees or those who would be enrolledpartly as the result of Medicaid expansion dto the implementation of the Affordable CarAct.

Payers & Providers stands by its reporting inthis matter. It will continue to report oncontinuing developments involvingCalOptima in future issues of the publicatio

On February 16,2012, the CalOptima boardof directors and certain members of the mediareceived an anonymous letter alleging conictof interest by Ed Kacic, chair of the CalOptimaBoard of Directors. The letter also alleged thatMary Ann Foo accepts payment for workingfor CalOptima while serving on the board ofdirectors.

Payers & Providers published a story based onthis letter on February 17, focusing only on theallegations against Mr. Kacic, andsubsequently ran an opinion column by JimLott of the Hospital Association of SouthernCalifornia that repeated the allegations.Despite what is contained in the anonymousletter and what is reported in Payers &Providers, the following are the facts:

I have reviewed the...letters signed by the

Irvine Health Foundation (IHF) boardof directors and the Managed System of Caresteering committee and believe theyaccurately state Mr. Kacic's action in thismatter.

Should you consider reporting on theallegations made against Mary Ann Foo, beassured that she has received no paymentfrom CalOptima while serving on our Board ofDirectors

The article appears to confuse a grantrequest by Orange County's Managed System

of Care to the federal Center for Medicare andMedicaid Innovation (CMMI) that would usethe IHF as a scal intermediary with the VCI-CalOptima Intergovernmental Transfer(lOT). The latter has the potential to alsoprovide funds to the Managed System of Care,but does not involve IHF, and the CMMI grantwould not nancially benet CalOptima.It would only result in recommendationsbeing made to our Board for consideration.CalOptima has been working with VCI on thelOT, which would draw down $12.7million in additional funds to Orange County.The Board has heard information items

about the potential to fund MSC with thefunds, but has taken no action. The IHF is notinvolved in these discussions.

The article stated that "an internal audit ...was critical of [Richard Chambers']leadership and suggested CalOptima has beenmismanaged." There was no internal auditbeing conducted at the time referenced, nor isthere one being conducted now. Thesource of this allegation is not an audit, but aleaked, preliminary and privileged

LETTER TO EDITOR
http://www.payersandproviders.com/publications/2012-03-09%20shinkman.pdfhttp://www.payersandproviders.com/publications/2012-03-09%20shinkman.pdfhttp://www.payersandproviders.com/publications/2012-03-09%20shinkman.pdfhttp://www.payersandproviders.com/publications/2012-03-09%20shinkman.pdf


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Payers & Providers PageOPINION

Addressing The Chronic Care CrisisImproving Outcomes is Linked to Better Coordinatio

Anne-Marie J. Audet, M.D., is vice preside

of health system quality and efficiency at

Commonwealth Fund. Shreya Patel is a

Commonwealth Fund program associate

op-ed is adopted from a blog entry they c

authored.

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MARKETPLACE/EMPLOYMENTPayers & Providers Page 5

SENIOR HEALTHCARE ANALYST

JOB SUMMARY: This position will support the HCC andEncounter Team in Health Care Informatics by collecting and ana-lyzing healthcare related data by performing data management,quality improvement studies and by conducting statistical analysisand generating reports for the organizations decision makers.

ESSENTIAL JOB RESULTS: Support operational needs byperforming complex analyses on a wide range of organizational

data - investigate and uncover root causes, identify trends, etc.and propose solutions. Achieve results by effectively leverag-ing expertise in healthcare/managed care data including, butnot limited to, membership, provider, claims, authorizations,pharmacy, and financial information. Commitment to customerservice achieved through timely, accurate, and supportabledeliverables. Support customer needs for what-if scenarioanalysis by developing analytical tools/models. Ensures under-standing of customer needs by proactively clarifying scope andrequirements and keeps customers apprised of project statusthrough effective communication. Achieves high-quality deliv-erables by assuring accuracy and thoroughness in executingprojects. Manages multiple (department) projects by effec-tively prioritizing work and communicating workload issues tomanagement. Develops and maintains up-to-date knowledge

of the Data Warehouse and other organizational data sources.Maintains professional and technical knowledge by attendingeducational workshops; reviewing professional publications;establishing personal networks; participating in professionalsocieties. Contributes to team effort by accomplishing relatedresults as needed.

QUALIFICATIONS: Bachelors Degree, or equivalent experiencerequired. 4+ years of proven analysis experience highly pre-ferred, or 2+ years of proven analysis experience in a Healthcare/Managed Care environment highly preferred. Ability to effec-tively interact with, and present findings to customers at all levelsof the organization including operational managers, medical direc-tors and executives required. Proficiency with MS SQL (queries)highly preferred. Clinical code knowledge related to claims/utili-zation highly preferred. Experience with managed care contractterms/analysis a plus. Experience in a Medicare Advantage envi-ronment a plus. Experience with MS BI products a plus. Expertskills in MS Office productivity software, especially MS Excel.Excellent technical, interpersonal, written and oral communica-tion skills required. Superior analytical skills required.

FT position, M-F 8 AM to 5 PM, with extended work hours andpossible travel, as needed. Apply to www.scanhealthplan.com

Job Opportunities Req. #11-540

MARKET EXPANSION PROFESSIONAL

JOB SUMMARY: Plan, design, and complete processes t

achieve business objectives for network and membershigrowth via market expansion. Manage and perform a broarange of tasks using resources effectively and efficiently tmeet identified timeframes for planned product and servicexpansions. This includes coordination of efforts and collaboration with external entities to meet all regulatory requirementand to ensure market expansion filings are fully compliant anapproved.

ESSENTIAL JOB RESULTS: Coordinate and execute completasks related to network and membership growth via markeexpansion, in order to ensure the successful completion oongoing cycles of work. Utilize detailed work lists to managthe timely completion of tasks for each phase of a particulamarket expansion process and provide necessary updates tmanagement, escalating risks as appropriate. Develop anmaintain positive relationships with internal departments anexternal entities, creating partnerships to achieve programobjectives. Effectively communicate and assign deliverableand timelines. Monitor and manage the assigned tasks tachieve timely completion. Monitor quality of tasks performed, develop and recommend process improvements foimplementation. Assure a quality market expansion procesoutcome by making sure that each finished task meets threquired level of quality. As needed, troubleshoot issues anprovide innovative solutions, focused on continuous qualitimprovement. Maintain professional and technical knowledgby attending educational workshops; reviewing professionapublications; establishing personal networks; participating i

professional societies. Contribute to team effort by accomplishing related results as needed.

QUALIFICATIONS: Bachelors Degree required. Preferred areof study: Business or Health Administration, Managemenor Process Engineering. Experience within HealthcareManaged Care, preferred. Demonstrated interpersonal skillwith the ability to compromise, persuade, and negotiatebe well-rounded and have excellent communications skillSolid leadership skills, excellent written and verbal communications skills and ability to establish effective workinrelationships with many different people, ranging from managers, supervisors, and professionals, to administrative ansupport staff personnel. Analytical, detail-oriented, flexibleand decisive. Ability to coordinate several activities at once

quickly analyze and resolve specific problems, and managdeadlines. Ability to work with minimal supervision, so neeto be self-motivated and disciplined. Expert skills in MOffice productivity software and strong computer skills aressential.

FT position, M-F 8 AM to 5 PM, with extended work hours andpossible travel, as needed. Must maintain valid drivers license,

automobile insurance and reliable transportation. Apply towww.scanhealthplan.com - Job Opportunities Req. #12-612


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Payers & Providers MARKETPLACE/EMPLOYMENT Page 6

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. 2Or e-mail: [email protected]

Or visit: www.payersandproviders.com

*New England Journal of Medicine, 2004.

SEEKING A NEW POSITION?

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Page 7Payers & Providers MARKETPLACE/EMPLOYMENT

Since 1959, Presbyterian Intercommunity Hospitalof Whittier has been committed to building a mutu-ally supportive health care team consisting ofpatient care givers, medical staff, volunteers and theboard of directors that have ensured our local popu-lation the highest quality of medical services in Los

Angeles County.

Our Home Health & Hospice departmentis currently seeking an

ASSISTANT DIRECTOR OF PATIENT SERVICES.

The Assistant Director of Patient Services is respon-sible and accountable for services provided topatients through Home Health and Hospice. Withdirection from the Director of Patient Services, theAssistant Director will assess and assist the Director

in all areas of operations, compliance, professionalstandards and IDS relationship.

Requirements include: Bachelors degree in Nursingor other health-related field. Valid CA RN license;BLS certification. At least 7 years of experience,5 of which must be in a home health agency. 3years of experience in a supervisory or administrativecapacity. Able to direct nursing, therapy and socialwork within the framework of regulations to care forpatients while understanding the rationale of rule-making in the industry. Must have an active interestin improving current level of skill and knowledge.

Beyond the benefits that come with working forthe areas leading community health care provider one that also recognizes the need to ensure patientsafety and comfort youll enjoy an extremely com-petitive compensation and benefits package. Plus,we use team concepts to encourage professionalgrowth and development.

Please apply online at www.pih.net,or [email protected].

Providence is calling aSENIOR FINANCIAL ANALYST OF REPORTIN

BUDGETING & PRACTICE ANALYSIS

to Providence Medical Institute, Torrance, CA.

In this position you will: Develop and maintain monfinancial reporting, prepare the annual budget, and supOperations management to identify and resolve finaopportunities in physician practices. The position willcreate, manage and track results of the annual OperaBudgets. Analyze physician compensation based on methodology.

Required qualifications for this position include:10 years of experience within a large healthcare orgation. Bachelors Degree in Accounting or Finance. Stanalytical skills with and expertise in using MicroOffice Access, Excel, PowerPoint, & Outlook. KnowledgLawson Financial Software.

Preferred qualifications for this position incluPhysician Compensation Analysis experience. MedGroup experience.

Providence Health & Services Southern California is furdeveloping its physician integration strategy. Historithe largest asset has been Providence Medical Institumedical foundation that provides administrative and osupport services to affiliated medical groups. ProvidMedical Institute is expected to grow significantly innext several years, bringing with it facilities, staff and sician growth to support that objective.

PROVIDENCE IS CALLING!

For immediate consideration, qualified candidates areencouraged to apply on-line at www.ProvidenceIsCalling

Apply Onlinehttp://bit.ly/providence06640Healthfax

Payers & Providers California Edition – Issue of March 15, 2012

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