Gasline Newsletter January 2009

Volume 10, No. 8

Prospect Decision

On January 8, 2009, with its decision in the Prospect Medical Group Inc. v. Northridge Emergency Medical Group case, the Supreme Court of California effectively ended the right of non-contracted physicians in California to directly bill Knox-Keene patients for emergency services. The high court unanimously overruled the earlier appellate court decision that had upheld the right of non-contracted physicians to bill Knox-Keene patients for unpaid balances on their accounts when the HMO had failed to make full payment for the emergency services rendered. Despite what CSA believed to be solid legal arguments in favor of the appellate court decision, the activist high court rode the wave of public sentiment in wanting to remove the patient from the line of fire between non-contracted physicians and risk-bearing organizations.

The Prospect ruling, coupled with the DMHC regulation last autumn, will force CSA to shift its focus from the defense of balance billing to the development of another mechanism to ensure reasonable payment for non-contracted services. For more information, please see the CMA toolkit in the “members only” section of the CSA Web Site at http://www.csahq.org/pdf/alerts/Bal_Bill_Toolkit_011409.pdf.

Call for Data: Out-of-Network Underpayment and Rescission of Treatment Authorization

CMA, CSA and other specialty physician associations have prepared a survey to gauge the impact of the recent DMHC regulation and Prospect ruling on physicians and patients. CMA is also gathering evidence concerning other, broader industry practices by health insurers that result in underpayment, or non-payment, for out-of-network services including rescission of coverage, and the use of the Ingenix database.

We strongly urge you or your billing service to complete the survey, as the results will play an invaluable role in our advocacy efforts. Predictions of harm will not sway lawmakers. Only factual information will provide physicians with the leverage needed to achieve a fast, fair and efficient dispute resolution process with the risk-bearing organizations. The data will not be used in a manner that reveals your identity. The survey is available online.

Palmetto Agrees to Alter Monitored Anesthesia Care Policy

Palmetto GBA—California’s Medicare Carrier—has corrected its overly restrictive Monitored Anesthesia Care policy. The policy was enacted during the transition from NHIC to Palmetto and omitted some procedures, including cataract surgery and colonoscopies, from the list of procedures for which MAC is routinely covered. Under the transition policy, MAC was only covered for those procedures for high-risk patients with a demonstrated medical necessity.

Palmetto has also agreed to retroactively pay previously denied claims for monitored anesthesia care. It is not yet clear whether the older claims will be automatically paid, or whether physicians will have to submit appeals.

CSA Annual Meeting

Save the date for the CSA 2009 Annual Meeting and Clinical Anesthesia Update: May 15-17, 2009, at the Hyatt Regency Monterey Resort & Spa on the Del Monte Golf Course. An optional Hands-On Ultrasound Workshop will be offered at the meeting.

CSA Nomination Forms are in the Mail

Nomination information for the positions of district director, delegate and alternate delegate, including job descriptions, lists of eligible members, and nomination forms for the 2009 elections have been mailed to the members of each district. Please complete your nomination forms and return them to the CSA office no later than Monday, February 9, 2009, at 5 p.m. The information and forms can also be found online at www.csahq.org in the “members only” section under elections.

Call for Submission of Resolutions for House of Delegates

Any CSA member may submit a resolution to the House of Delegates (your elected representatives) on any issue that he or she deems important. A resolution is a proposal that the CSA undertake an activity related to a current issue of concern to anesthesiologists. For example, a resolution might recommend that the CSA develop a guide on issues that should be addressed when contracting with a billing service. For assistance in formulating a resolution, please contact Johnathan L. Pregler, M.D., Speaker of the House of Delegates. The deadline for submissions is March 15, 2009.

The House of Delegates will meet on Saturday, May 16, as part of the CSA Annual Meeting at the Hyatt Regency Monterey Resort & Spa, Monterey, California. For more information, contact the CSA office at 650-345-3020, 800-345-3691, or fax 650-345-3269.

Committee Appointments

Active and resident members who are interested in becoming more involved in the CSA and would like to start by serving on a committee need to contact Linda B. Hertzberg, M.D., President-Elect, at lhertzberg@comcast.net or the CSA office at 800-345-3691 or csa@csahq.org by February 15, 2009, indicating interest in the divisions and committees listed below. For more information about the committees and divisions, call the CSA office or refer to the CSA Bylaws at http://www.csahq.org/pdf/csa_bylaws.pdf.

Divisions:

Educational Programs Division
Legislative and Practice Affairs Division
Standing Committees:

Committee on Bylaws
Committee on Finance and Administration
Committee on Peer Review
Committee on Public and Professional Communications
Special Committees:

Committee on Physicians Health and Well Being
Michael W. Champeau, M.D.
President

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