SMCMA Physician

Healthcare Dream Team

California physicians have a powerful ally when it comes to dealing with problematic payors—the California Medical Association (CMA) Center for Economic Services (CES). Staffed by practice management experts with a combined experience of more than 125 years in medical practice operations, the CES team has recovered $29 million on behalf of its physician members over the past 10 years. 

Each member of the CES team brings something unique to the table, allowing them to bounce ideas off each other when trying to help practices.

“We are the dream team of health care,” said Mark Lane, CES Director of Publications and Resources. “There are few issues presented that we do not have experience dealing with in some capacity. We can also draw upon our vast network of contacts to find a resource or point person to help address almost any issue. No other organization, that I am aware of, can assist physicians or their practices on this level,” said Lane. 

Lane began his career as a claims processor for plans such as Blue Shield of California and Health Net. Before long, he had moved up to a position in provider relations, allowing him to get a unique vantage point on the relationship between physicians and payors.

 

Empowering Physician Practices

CES also provides one-on-one practice management assistance to physician members and their staff on reimbursement, practice operations and contract-related issues. The center’s goal is to empower physician practices by providing resources and guidance to improve practice success. Assistance ranges from coaching and education to direct intervention with payors or regulators.

“The ultimate goal is to empower practices to be able to advocate successfully for themselves,” said CES Vice President Jodi Black. “Sometimes processes fail and that’s when we intervene on their behalf.”

In the first three quarters of 2018, CES recovered more than $9 million on behalf of physician members, up from $3 million in all of 2017. One of the biggest success this year was getting Anthem Blue Cross to agree not to pursue a $4.2 million recoupment from a member practice.

Anthem had notified the practice it was planning to recoup more than $4 million due to problems with the renewal of a fictitious name permit. CMA escalated the issue to Anthem’s medical director, highlighting that upon renewal, the medical board showed no lapse in the permit. As a result, Anthem agreed not only to not pursue the recoupment, but also to release  approximately $600,000 in pending claims for payment.

Another success story was getting Medicare to agree to reinstate billing privileges and release almost $1 million in pending payments to another practice that had its billing privileges revoked when Medicare discovered an undisclosed criminal offense by a practice employee. 

CMA, the American Medical Association and Noridian, California’s Medicare Administrative Contractor, worked together to get the practice’s appeal reviewed within three days, rather than the normal 90 days as allowed by law, to help get the practice’s billing privileges reinstated and avoid overpayments dating back nine years.

“This is money that would have likely gone unrecouped if we didn’t step in,” said Black, who has been with CMA for 14 years, building relationships with both physicians and payors on behalf of CMA. Prior to joining CMA, she spent 15 years working with a group of emergency physicians, a field she entered while still in college. She changed her major to health care administration because she believed in the cause so much. 

CES is constantly developing resources and tools to assist practices with new laws, including its monthly CMA Practice Resources newsletter, webinars, seminars and phone conversations. These services are free to all members. 

“It feels great to help our doctors, so they can get back to work helping their patients,” said Juli Reavis, CES Associate Director, who focuses largely on helping physicians with California’s new out-of-network billing and payment law (AB 72). The law, which went into effect July 1, 2017, placed limits on what physicians can bill patients for using an out-of-network physician at in-network facility. CES has created more than 10 new resources to help practices succeed and comply with these new requirements. 

 

You Are Not Alone

In just the first eight months of 2018, CES assisted physicians and their office staff with nearly 900 calls from 555 different practices within 30 different component medical societies. Seventeen percent of those calls were from first-time callers.

Often, the only way CES finds out about an issue is by members contacting the call center. Typically, if an issue is affecting one practice, it’s impacting others. Small errors, sometimes on the part of the payor, sometimes on the part of the physician, can have a snowball effect.

“Our goal is to take the noise out of the system so doctors can get back to treating patients,” said Black. 

“I always felt a need to help others and prevent pain and suffering wherever I could,” said Lane. “The role I serve at CMA, assisting physicians and their practice staff, has given me the opportunity to fulfill my mission. It’s the most rewarding role I have ever had in my 25 years of health care.”

Tina Tedesco is a freelance writer in Sacramento