Public Payer Archive
Please select the links below for complete Public Payer articles and events of previous years. View Current Public Payer News
General
11.16.09 AMA alerts address unfair payer practices
The American Medical Association has introduced a free resource that addresses unfair payer practices and which offers a variety of other practice management resources and tools.
Click here to sign up for AMA's "Practice Management Alerts"
10.27.09 New AMA resource helps physician practices prepare for ICD-10 implementation
As of Oct. 1, 2013, the existing ICD-9 diagnosis and procedure code sets will be replaced by ICD-10-CM (diagnosis code set) and ICD-10-PCS (procedure code set). The ICD-10 diagnosis code set has much more specificity in the codes, increasing the code set from 14,000 to 68,000 codes. The AMA has prepared resources to help physicians and their practice staff prepare for these changes.
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10.23.09 Q&A's on UnitedHealthcare's Premium Designation program for physicians
Read full Q&A
08.31.09 NCHICA, WEDI release ICD-10 timeline deadline
NCHICA and WEDI have released the timeline for ICD-10 implementation, which highlights the need for all segments of the health care industry to start planning now to meet the October 1, 2013 compliance deadline.
The timeline was developed by the NCHICA-WEDI Timeline Initiative, a collaboration of provider, health plan and vendor representatives serving on several workgroups. It details the steps and time required for each industry segment (providers, plans and vendors) to effectively implement this major change in how the health care industry identifies diagnoses and inpatient hospital procedures.
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07.31.09 CMS to exclude some drugs from Medicare pay formula
The American Medical Association (AMA) says that the Centers for Medicare and Medicaid Services (CMS) has released the proposed Medicare physician payment schedule rule for 2010, including a “long-awaited announcement that the Obama Administration will change the definition of physician services under the SGR to exclude physician-administered drugs.” AMA is reporting that the drug costs will be removed retroactive to the 1996/97 base year of the SGR formula, which will greatly lessen the forecast SGR cuts in future years, although there is still a 21.5 percent cut scheduled for 2010.
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07.06.09 New AMA resources address risk assessment, adjustment models
The American Medical Association has introduced two new resources that address how the risk assessment and risk adjustment models that health insurers use affect physician practices.
- An introduction to risk assessment and risk adjustment models defines the terms "risk assessment" and "risk adjustment." It also provides an overview of the prominent risk assessment and risk adjustment models, including profiling for physicians and other health care professionals.
- Terminology used in physician profiling helps physicians by defining common profiling terms used in health insurers' physician profiling programs.
Click here for the new resources
05.11.09 New resource to help physicians get paid in timely, accurate way
The Physicians Advocacy Institute's (PAI) Health Claims Data Warehouse is introducing an innovative online tool that will enable physicians to confirm the accuracy of their claims payments in a simple and automated way. PAI's MDEdge will provide detailed information about the claims that physicians submit to health insurers, according to Project Manager David Ginsberg.
PAI is currently preparing for the system's testing phase, Ginsberg says. He confirms that this includes a number of Medical Association of Georgia (MAG) member practices. Ginsberg says he expects MDEdge to be rolled out in full in January 2010. And while a subscription fee has not yet been fixed, he says PAI's plan is to keep the cost affordable for physicians.
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02.27.09 MAG study highlights problems associated with prior authorization
Under the direction of MAG's Third Party Payer Committee, MAG staff recently completed a study of the effects of the prior authorization process on physicians and their patients in Georgia.
"Prior authorization continues to play an integral role in today’s managed health care plan operations," says John A. Goldman, M.D., an Atlanta-based rheumatologist who chairs the Third Party Payer Committee. "Unfortunately, the health plans have failed to adequately define the value associated with prior authorization requirements."
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Read Executive Summary of the Third Party Payer Department's findings
Read full study from Third Party Payer Department
06.06.07 MAG's White Paper on Pay-for-Performance
Physicians in Georgia and throughout the country currently are being subjected to so-called “Pay-for-Performance” (PFP) programs as an evaluation method for determining reimbursement for the medical care they provide. At its onset, many physicians have been very skeptical about PFP programs and the veracity of their alleged purpose. At one extreme, some believe that PFP is a direct attack on the practice of medicine and fails in its goal to support high quality and high value care. Others believe it is a step forward in medicine, allowing doctors and their patients to get a clearer view of what they do to treat illness, how effective it is and at what cost.
What does PFP actually do? How did this trend begin? How do these programs actually work? How widespread are they? What are its merits or deficiencies? And, finally, what role, if any, has medicine played in this new movement? In this paper, MAG hopes to answer these questions and provide physicians a general understanding of PFP and what it may mean for your practice. We also think it is important to identify the pitfalls of PFP and suggest ways it could be improved.
Read White Paper on Pay-For-Performance
Department of Community Health
12.15.09 State Health Benefit Plan 2010 enrollment update
The Georgia Department of Community Health (DCH) administers the State Health Benefit Plan (SHBP). It is a self-funded plan, which means that all expenses are paid by employee premiums and employer funds. Approximately 75 percent of the cost is funded by DCH, with the employee paying approximately 25 percent. The Open Enrollment dates were October 9 through November 10, 2009. Changes include...
Read DCH update
Click here for DCH presentation
08.13.09 MAG Summary of DCH Meeting
Click here for notes
06.05.09 DCH plan to cut injectables payment for Medicaid on hold
The Georgia Department of Community Health (DCH) Commissioner Rhonda Medows, M.D., has said that DCH will place on hold its plans to reduce the maximum amount that health care providers can be paid for injectable drugs that are administered in an office or outpatient setting for Medicaid services in Atlanta. It was considering the change effective July 1. Dr. Medows said that the subject will not be discussed at the DCH board meeting on June 11, adding that DCH will continue to review "input and options." The proposed change would have affected Medicaid and PeachCare for Kids providers, including physicians, physician assistants, nurse midwifes, advanced nurse practitioners, podiatrists, oral maxillofacial surgeons, and related providers eligible to administer injectable drugs. Both MAG and the Georgia Society of Clinical Oncology (GASCO) testified against the cuts at a meeting on May 26. Those wishing to comment on the proposed changes should submit written comments to the Board of Community Health, P.O. Box 1966, Atlanta, 30303.
05.27.09 DCH calling for cut in reimbursement for injectables for Medicaid
The Georgia Department of Community Health has proposed that the maximum amount that health care providers can be reimbursed for injectable drugs that are administered in an office or outpatient setting for Medicaid services in Atlanta be reduced to 80 percent of the 2007 CMS rate beginning July 1, 2009. The Medicaid and PeachCare for Kids providers that are subject to this change include, but may not be limited to, physicians, physician assistants, nurse midwifes, advanced nurse practitioners, podiatrists, oral maxillofacial surgeons, and related providers eligible to administer injectable drugs. Both MAG and the Georgia Society of Clinical Oncology (GASCO) testified against the cuts at a meeting on May 26. Citizens wishing to comment in writing on the proposed changes should do so on or before June 4, 2009, to the Board of Community Health, P.O. Box 1966, Atlanta, 30303.
Read MAG's testimony to DCH
Notice from DCH
05.21.09 DCH announces member encounter validation activities
The Georgia Department of Community Health has contracted with Myers and Stauffer LC to assess the accuracy and completeness of encounter data provided by the CMOs to DCH.
Read the letter to providers
02.27.09 MAG, DCH promote electronic health records to consumers
MAG is working with the Georgia Department of Community Health to promote new communications resources that are designed to help consumers in Georgia understand the benefits associated with Electronic Health Records (EHRs) – as well as the safeguards that protect the security and privacy of their health information. Georgia is one of many states and territories involved in the Consumer Education and Engagement initiative of the Health Information Security and Privacy Collaboration (HISPC), an effort to raise the awareness of the value and benefit of storing, exchanging and accessing health information electronically. Physicians who are interested in obtaining brochures or posters can contact Lisa Marie Shekell at lshekell@dch.ga.gov or at 404.657.9118.
Click here for more information
02.27.09 HHS issues final rule for implementing ICD-10
The Department of Health and Human Services (HHS) recently released its final rule to replace the ICD-9-CM code sets that are used to report health care diagnoses and procedures in electronic health care transactions. The new codes sets, known as ICD-10-CM/PCS, are expanded and more precise. Responding to hospitals’ concerns, the final rule calls for a compliance deadline of October 1, 2013 – two years later than proposed. In a separate rule, HHS adopted for electronic transactions the updated X12 standard (Version 5010), which is needed to use the ICD-10 codes, and the National Council for Prescription Drug Programs standard.
Electronic Medical Records
Managed Care Contract
12.01.02 15 Questions to Ask Before Signing a Managed Care Contract
View PDF
Practice Updates
12.12.07 Tiered and Narrow Physician Networks: How to Challenge your Profile or Placement
MAG's offices of the General Counsel and Third Party Payer Advocacy have teamed up with the AMA to disseminate a flyer giving tips on ways to challenge and improve your profile or placement.