Page 1 of 1 Resolution TITLE: MODIFICATIONS TO THE ... 401-13 TITLE: MODIFICATIONS TO THE AFFORDABLE...

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Resolution 401-13 TITLE: MODIFICATIONS TO THE AFFORDABLE CARE ACT

Author: Paul Kirz, MD Contact: [email protected]

Introduced by: Paul Kirz, MD

Reference Committee D Endorsed by:

October 11 - 13, 2013 This resolution constitutes a proposal for consideration by the California Medical Association

House of Delegates and does not represent official CMA policy.

WHEREAS, the Affordable Care Act (ACA) mandates both employer and individual health 1 insurance or payment of additional federal tax; and 2 3 WHEREAS, the health insurance mandate of the ACA may discourage employers from hiring 4 full time employees and could result in severe financial hardship for lower income families; and 5 6 WHEREAS, the ACA raises the federal income tax deductibility of health care expenses to 7 greater than 10% of one’s adjusted gross income; therefore be it 8 9 RESOLVED: That CMA support legislation modifying the ACA health insurance 10

requirement to a high deductible catastrophic health insurance instead of the 11 current ACA mandated health insurance; and be it further 12

13 RESOLVED: That CMA support legislation modifying the ACA to allow full federal and 14

state income tax deductibility of all out of pocket health care expenses; and 15 be it further 16

17 RESOLVED: That this matter be referred for national action. 18 19 Current CMA Policy: 20 CMA supports requiring all health plan issuers in California to offer at least one standardized catastrophic and 21 preventive health care policy. (HOD 216a-05) CMA further supports making individual catastrophic health 22 insurance mandatory for all Californians. (HOD 205-04) On the other hand, CMA policy supports offering patients 23 a wide variety of health plan options to meet their individual needs, with all plans required to meet or exceed a 24 defined minimum benefits package. (HOD B-4-08) 25 26 Fiscal Impact: 27 Within budget to adopt as policy and request action by the AMA; however, the cost of CMA sponsoring or 28 opposing a federal bill could be $130,000 or more and is dependent on many factors over which CMA has no 29 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 30 resources by opponents and proponents. 31

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Resolution 402-13 TITLE: 90-DAY GRACE PERIOD

Author: Laurie Reynard, MD Contact: [email protected]

Introduced by: Laurie Reynard, MD

Reference Committee D Endorsed by: District IV Delegation



WHEREAS, the U.S. Department of Health and Human Services (HHS) made the decision to 1 allow federally subsidized patients (<400 percent of FPL) a 90-day grace period for nonpayment 2 of premiums, which presents a large risk for providers who contract with the exchange’s 3 qualified health plans (QHPs); and 4 5 WHEREAS, the plan has the option to pend claims for services performed in the 2nd and 3rd 6 months of delinquency until the enrollee pays the outstanding premium balance; and 7 8 WHEREAS, the plan has the option to deny all claims for services performed in the 2nd and 3rd 9 months of delinquency if the enrollee is terminated after 3 months of delinquency; and 10 11 WHEREAS, the provider may not be notified that the patient is delinquent in their premiums 12 and that claims may be pended and denied should the coverage be terminated, until after the 13 services have been provided, upon receipt of a claim; and 14 15 WHEREAS, the grace period provision could strain the physician-patient relationship, and 16 significantly impact practice viability and access to care; therefore be it 17 18 RESOLVED: That CMA demand that the Department of Managed Health Care require that 19

insurance companies involved in health insurance exchanges make it clear on 20 the insurance cards which patients are federally subsidized, provide a user-21 friendly hot-line or fax back for authorization at the time of service and 22 guarantee payment for those claims with authorization, and that authorization 23 will guarantee payment of the claim regardless of final coverage status; and 24 be it further 25

26 RESOLVED: That physicians have the right to collect payment at time of service or refuse 27

treatment to those patients whose guarantee of coverage cannot be verified at 28 time of service; and be it further 29

30 RESOLVED: That this matter be referred for national action. 31 32 Current CMA Policy: 33 CMA supports requiring that payors make electronically available all the information needed to verify patients' 34 eligibility of insurance, status of the amount of deductible remaining and the correct mailing address for sending 35 claims, and that all such information be current. (HOD 412-00) CMA further supports requiring that insurers and 36

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D health plans issue health insurance cards that clearly identifies the plan, IPA or medical group where appropriate, 1 and the coverage of the patient, and that all inquiries about coverage must be answered promptly by the company 2 issuing the cards. (HOD 426-96) CMA also supports the inclusion of an accessible 800-number for accessing health 3 plan services (e.g., prior authorization, patient eligibility, and visits authorization), among other things. (HOD 403-4 97) Finally, CMA supports requiring the use of “swipe card” technology with insurance cards for the purposes of 5 verifying insurance eligibility and enabling faster insurance payment for medical services at the point of delivery. 6 (HOD 427-12) 7 8 Fiscal Impact: 9 Within budget to adopt as policy and request action by the AMA; however, if CMA were to undertake the advocacy 10 that would be required, costs could be as high as $130,000 and is dependent on many factors over which CMA has 11 no control, such as the extent of external opposition or support for the proposal, communications, and commitment 12 of resources by opponents and proponents. 13

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Resolution 403-13 TITLE: REQUIRE ALL HEALTH INSURERS TO ACCEPT COVERED CALIFORNIA PATIENTS

William Hale, MD Contact: [email protected]

Introduced by: William Hale, MD




WHEREAS, a major principle of the Affordable Care Act was the notion that all would be covered and 1 that no one would be subject to adverse selection and denied insurance coverage; and 2 3 WHEREAS, the payments that are likely to be received under the Affordable Care Act in the State of 4 California are likely to be less than those received on the open private insurance market; and 5 6 WHEREAS, failure to participate in the Covered California market would in fact be a continuation of 7 the adverse selection policies of the previous unregulated market; and 8 9 WHEREAS, those entities that are bearing risk in the healthcare market are licensed under the 10 health and life section of the California insurance law; and 11 12 WHEREAS, the life insurance policies are enormously lucrative primarily due to a systematic adverse 13 selection and misrepresentation resulting in a systematic and legally sanctioned unjust enrichment; 14 therefore be it 15 16 RESOLVED: That all risk bearing health care providing entities in the State of California shall be 17

required to accept a pro rata share of the Covered California patients pool. 18 19 Current CMA Policy: 20 None. 21 22 Fiscal Impact: 23 No cost to adopt as statement of policy. 24

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Resolution 404-13 TITLE: UNIVERSAL ELECTRONIC CLAIMS SUBMISSION

Author: Donaldo Hernandez, MD Contact: [email protected]

Introduced by: Santa Cruz County Medical Society




WHEREAS, conducting administrative related activities is among one of the main drivers of 1 costs of care in the complex medical delivery system in California; and 2 3 WHEREAS, healthcare administrative cost approach $361 billion dollars annually in the 4 United States; and 5 6 WHEREAS, physician claims submission is a necessary part of receiving, reviewing and 7 processing physician services; and 8 9 WHEREAS, the current claims submission process is fractionated and acts a significant source 10 of cost of care via increased overhead demands which include but are not limited to collecting 11 copayments, seeking prior authorization, coding of services delivered, checking and submitting 12 claims, receiving and depositing payments, appealing denials and underpayments, collecting 13 from patients, negotiating end-of-year resolution of unsettled claims, and paying subcontracted 14 providers such that physicians are spending hundreds of thousands of dollars annually as they 15 attempt to collect appropriate payment for services rendered; and 16 17 WHEREAS, the Patient Protection and Affordable Care Act (ACA) of 2010 expressly seeks to 18 improve the quality and efficiency of health care delivered in the United States such that it 19 expressly requires the DHHS to set detailed rules for processing administrative interactions and 20 imposes financial penalties on health plans that do not adopt standardized procedures; therefore 21 be it 22 23 RESOLVED: That CMA request the California State Legislature to draft and pass 24

legislation that will require the development of a single, budget neutral 25 universal electronic claims system for all health plans conducting care under 26 the Covered California/ Healthcare Exchange program including all state 27 sponsored entities acting as health plan providers within the State of 28 California; and be it further 29

30 RESOLVED: That any supplemental information required to approve a claim be uniform 31

and limited to diagnosis and date of service related data, thus eliminating the 32 need to complete multiple unique interactions for each health plan entity; and 33 be it further 34

35


D RESOLVED: That CMA assist and facilitate that process. 1 2 Current CMA Policy: 3 Longstanding policy states that CMA will continue its strong support of a simplified uniform billing form for 4 mandatory use in all third party health insurance billing. (HOD 101-74) 5 6 Fiscal Impact: 7 No cost to adopt as policy. If legislation is required, the potential cost is speculative and dependent on many 8 factors over which CMA has no control, such as the extent of external opposition or support for the proposal, 9 communications and commitment of resources by opponents and proponents. The cost of CMA sponsoring or 10 opposing a bill could be $95,000 or more; in individual legislative actions, costs can be much higher. Endorsement 11 or support of bills sponsored by others requires less effort and less cost. 12

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Resolution 405-13 TITLE: REDUCING ADMINISTRATION BURDENS IN HEALTH REFORM

Author: Medium and Large Group Mode of Practice Forums

Introduced by: Medium and Large Group MOPFs

Reference Committee D Endorsed by: Medium and Large Group MOPFs



WHEREAS, the United States, and California with it, is entering an era of potentially 1 significant new administrative demands on the healthcare delivery system as a result of reforms 2 brought on by the Patient Protection and Affordable Care Act; and 3 4 WHEREAS, California’s health benefit exchange, Covered California, will require more than 5 seventy reports of participating health plans and new reporting requirements on physicians; and 6 7 WHEREAS, states like Oregon (SB 604) and Texas (SB 1150) have moved to proactively 8 reduce the administrative burdens on physicians this year; and 9 10 WHEREAS, California should be the model for reducing unnecessary administrative waste and 11 burdens in the healthcare delivery system; therefore be it 12 13 RESOLVED: That CMA support the reduction of administrative burdens on physicians 14

in the implementation of health care reforms to the greatest extent 15 possible; and be it further 16

17 RESOLVED: That CMA support legislation mandating the use of a uniform 18

credentialing process and form; and be it further 19 20 RESOLVED: That CMA support legislation mandating the use of a uniform prior 21

authorization process and form for medical services; and be it further 22 23 RESOLVED: That CMA urge California’s health benefit exchange to require 24

administrative simplification by participating health plans and monitor 25 the health plans progress in reducing unnecessary administrative burdens 26 on the delivery system. 27

28 Current CMA Policy: 29 HOD 407-01directed CMA to work with health plans, IPAs, and medical groups to create a uniform treatment 30 authorization form available in both paper and electronic format. CMA also supports ensuring that physicians 31 have access to fast, effective and efficient prior authorization and coverage inquiry processes. (HOD 112a-06) 32 Longstanding policy states that CMA will continue its strong support of a simplified uniform billing form for 33 mandatory use in all third party health insurance billing. (HOD 101-74) 34 35 Fiscal Impact: 36


D The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 1 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 2 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 3 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 4 requires less effort and less cost. 5

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Resolution 406-13 TITLE: PHYSICIAN CONTRACTING WITH MAJOR HEALTH PLANS

Author: Michael Borok, MD Contact: [email protected]

Introduced by: Michael Borok, MD




WHEREAS, current law states that when a health insurance company sends a contract revision 1 or amendment(s) to a currently contracted physician, the physician has 45 days to respond 2 amending the updated or revised contract and sending that contract back to the health insurance 3 company signed by the physician or accepting the new contract as is without sending it back to 4 the health plan; and 5 6 WHEREAS, the solo, small group, and mid-sized group physician has no market leverage 7 when contracting with the major health insurance companies, resulting in a "take it or leave it" 8 decision when contracting with a major health insurance company; therefore be it 9 10 RESOLVED: That CMA support legislation requiring that health insurance company 11

contract revisions, changes and amendments that are more than only fee 12 schedule changes require the physician to sign and return the health insurance 13 company revised, updated or amended contract to the health insurance 14 company within the 45 day review period only if that physician accepts that 15 revised, amended or changed contract; and be it further 16

17 RESOLVED: That CMA support legislation allowing physicians who do not accept the 18

health insurance company updated, revised, or amended contract not to return 19 the contract and by not returning the contract within the 45 day period then 20 the previous contract remains in force between the physician and the health 21 insurance company; and be it further 22

23 RESOLVED: That CMA support legislation that makes it illegal to write a contract that can 24

be modified without the signed consent of both parties. 25 26 Current CMA Policy: 27 None. 28 29 Fiscal Impact: 30 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 31 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 32 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 33 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 34 requires less effort and less cost. 35

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Resolution 407-13 TITLE: REIMBURSEMENT FOR TELEPHONE/ELECTRONIC PATIENT MANAGEMENT

Author: Len Doberne, MD Contact: [email protected]

Introduced by: Len Doberne, MD




WHEREAS, certain medical care can be provided by physician communication with patients 1 by telephone or other electronic means without direct face-to-face patient contact; and 2 3 WHEREAS, such care may not be associated with a recent or emergently upcoming patient 4 visit, and CPT codes 99441, 99442, 99443, and 99444 have been established to codify such 5 separately identifiable patient care interactions; and 6 7 WHEREAS, such medical care requires the time, judgment, and documentation of medical care 8 provided; and 9 10 WHEREAS, such medical care can be more time effective for both physicians and patients, and 11 reduce environmentally costly physical transportation of patients to the physicians’ office/clinic; 12 and 13 14 WHEREAS, most medical insurance companies routinely deny payment for such care provided 15 by contracted physicians and often simultaneously prohibit physicians from billing patients for 16 such care provided; therefore be it 17 18 RESOLVED: That CMA sponsor legislation requiring health insurance companies licensed 19

in the State of California to pay contracted physicians (with applicable co-20 pays and deductibles) for telephone or other electronic patient management 21 services such as defined by CPT codes 99441, 99442, 99443, and 99444 22 (copyright American Medical Association) in amounts similar to the 23 amounts paid for office visits with similar complexity and time expenditure, 24 including the time taken for associated activities required to complete these 25 services (contacting consultants, sending orders to lab or x-rays, transmitting 26 prescriptions, possibly calling the patient back to confirm or adjust plans, and 27 completing records, etc.). 28

29 Current CMA Policy: 30 In 2012, the House of Delegates referred a similar resolution (Res. 418-12) to the Board of Trustees for decision. 31 The Board adopted the following substitute at its July 26, 2013 meeting: 32

RESOLVED: That CMA encourage group practices to recognize the physician time and effort required for 33 provision of telephone and other electronic patient management services; and be it further 34


D RESOLVED: That CMA continue to advocate for requiring plans and insurers to recognize telephone or 1 other electronic patient management services as covered services to be reimbursed or paid in amounts 2 proportional to the time and associated activities required to complete these services (preparing records, 3 transmitting prescriptions, contacting consultants, etc.) for office visits with similar complexity and time 4 expenditure, and if not paid, such insurance companies shall not prevent physicians from billing patients 5 directly for provision of these services; and be it further 6 RESOLVED: That CMA support legislation that advocates for regulatory change requiring plans and 7 insurers to recognize telephone or other electronic management services as a covered service to be 8 reimbursed or paid in amounts proportional to the time and associated activities required to complete these 9 services, or in the alternative legislation that would not prevent physicians from billing patients directly for 10 the provision of these services. 11

CMA longstanding policy states that physicians should be fairly and uniformly compensated for their professional 12 services whether patients are treated in face-to-face contact, by telephone consultation, fax, E-mail or other 13 communication form. (HOD 401-00) On the other hand, CMA policy supports the designation of telephone, fax, 14 and email services as non-covered benefits in order to facilitate patient payment for these services. (HOD 413a-04) 15 16 Fiscal Impact: 17 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 18 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 19 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 20 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 21 requires less effort and less cost. 22

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Resolution 408-13 TITLE: RETRO-AUTHORIZATION FOR TESTS/PROCEDURES

Author: Susan Sprau, MD Contact: [email protected]

Introduced by: Susan Sprau, MD

Reference Committee D Endorsed by: California Chapter of the American College of Physicians



WHEREAS, many third party payers are adding prior authorization requirements for 1 tests/procedures at a rate that is difficult for physicians to keep abreast of; and 2 3 WHEREAS, at least one third party payer has elected to not provide a retro-authorization 4 process for tests requiring a prior authorization; and 5 6 WHEREAS, the California Department of Insurance and the Department of Managed Care do 7 not require insurers to provide a retro-authorization process; and 8 9 WHEREAS, physicians may incur significant financial costs for medically necessary 10 tests/procedures that require a prior authorization, merely because they were not aware of the 11 need for a prior authorization; and 12 13 WHEREAS, CMA is committed to decreasing the “hassle factor” in health care; therefore be it 14 15 RESOLVED: That CMA support inclusion of a requirement for a retro-authorization 16

process in all physician-insurer contracts, including CMA sample contracts, 17 with requirements that the timeframe for consideration be the same as urgent 18 appeals, and with similar provisions for third party review of appeal denials; 19 and be it further 20

21 RESOLVED: That CMA work with the California Department of Insurance and the 22

Department of Managed Health Care to mandate that insurers, IPAs, etc., 23 provide a retro-authorization process for all tests/procedures that require a 24 prior authorization with requirements that the timeframe for consideration be 25 the same as urgent appeals, and with similar provisions for third party review 26 of appeal denials; and be it further 27

28 RESOLVED: That this matter be referred for national action. 29 30 Current CMA Policy: 31 CMA supports third-party payers providing an “urgent” prior authorization system where approvals can be granted 32 within four hours, including nights and weekends, and a prompt (5-minute maximum) electronic and phone access 33 for prior authorization. (HOD A-2-08) CMA also supports ensuring that physicians have access to fast, effective 34 and efficient prior authorization and coverage inquiry processes. (HOD 112a-06) 35 36


D Fiscal Impact: 1 Within budget to adopt as policy and request action by the AMA; however, if CMA were to undertake the advocacy 2 that would be required, costs could be as high as $130,000 and is dependent on many factors over which CMA has 3 no control, such as the extent of external opposition or support for the proposal, communications, and commitment 4 of resources by opponents and proponents. If legislation is required, the potential cost is speculative and dependent 5 on many factors over which CMA has no control, such as the extent of external opposition or support for the 6 proposal, communications, and commitment of resources by opponents and proponents. The cost of CMA 7 sponsoring or opposing a bill could be $95,000 or more; in individual legislative actions, costs can be much higher. 8 Endorsement or support of bills sponsored by others requires less effort and less cost. 9

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Resolution 409-13 TITLE: REQUIREMENT TO STUDY ACCESS TO MEDICAL TREATMENT BY ADMINISTRATIVE DIRECTOR OF DEPARTMENT OF WORKERS COMPENSATION

Author: Michael Bazel, MD Contact: [email protected]

Introduced by: Michael Bazel, MD




WHEREAS, Labor Code 5307.2 states “the administrative director shall contract with an 1 independent consulting firm, to the extent permitted by state law, to perform an annual study of 2 access to medical treatment for injured workers,” and 3 4 WHEREAS, based on such study, if deficiency is detected, the adjustment to the fees or other 5 factors in order to improve the access could be made; and 6 7 WHEREAS, despite all the difficulties imposed by new legislative laws and many qualified 8 physicians leaving the field of Workers Compensation, no such studies are regularly conducted; 9 therefore be it 10 11 RESOLVED: That CMA work with the State Legislature to amend Labor Code Section 12

5307.2 to change the language of “the administrative director shall contract 13 with an independent consulting firm, to the extent permitted by state law, to 14 perform an annual study of access to medical treatment for injured workers” 15 to “the administrative director must … perform an annual study”; and be it 16 further 17

18 RESOLVED: That CMA work with the Legislature to make sure the law requiring an 19

independent consulting firm, to the extent permitted by state law, to perform 20 an annual study of access to medical treatment for injured workers is 21 enforced. 22

23 Current CMA Policy: 24 None. 25 26 Fiscal Impact: 27 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 28 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 29 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 30 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 31 requires less effort and less cost. 32

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Resolution 410-13 TITLE: MERGING PREMIUMS FOR COVERED CALIFORNIA AND WORKERS’ COMPENSATION PROGRAMS

Author: William Hale, MD Contact: [email protected]

Introduced by: William Hale, MD




WHEREAS, injured workers have historically had an excellent healthcare program giving 24-1 hour coverage and including disability benefits; and 2 3 WHEREAS, Covered California is now going to bestow a major portion of these benefits for 4 the whole public; and 5 6 WHEREAS, this double benefit represents a unnecessary duplication of costs to the employer; 7 therefore be it 8 9 RESOLVED: That employers who offer a platinum level or equal coverage to all employees shall 10

be allowed to be exempt from the health care portion of the workers’ compensation 11 premium. 12

13 Current CMA Policy: 14 None. 15 16 Fiscal Impact: 17 No cost to adopt as policy. If legislation is contemplated, the potential cost is speculative and dependent on many 18 factors over which CMA has no control, such as the extent of external opposition or support for the proposal, 19 communications and commitment of resources by opponents and proponents. The cost of CMA sponsoring or 20 opposing a bill could be $95,000 or more; in individual legislative actions, costs can be much higher. Endorsement 21 or support of bills sponsored by others requires less effort and less cost. 22

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Resolution 411-13 TITLE: ENFORCING RULES SET FOR INDEPENDENT MEDICAL REVIEW






WHEREAS, on 8/31/12, the California Legislature passed a new Workers’ Compensation 1 Reform Bill (SB863); and 2 3 WHEREAS, as part of the report, Independent Medical Review (IMR) has been established to 4 resolve UR denials; and 5 6 WHEREAS, IMR opinion is final and it cannot be overturned based on anything beyond fraud; 7 and 8 9 WHEREAS, there is nothing in the Labor Code to make reviewers adhere to the rules; therefore 10 be it 11 12 RESOLVED: That CMA work with legislators to allow dismissal of the Workers’ 13

Compensation Independent Medical Review if the reviewer fails to follow 14 the rules set by the Labor Code. 15

16 Current CMA Policy: 17 HOD 205-80 urged the Department of Health Services to retain physicians and other advisory or consultant 18 personnel who are sufficiently well trained medically to responsibly review claims and requests for hospitalization. 19 20 Fiscal Impact: 21 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 22 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 23 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 24 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 25 requires less effort and less cost. 26

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Resolution 412-13 TITLE: UTILIZATION REVIEW AND INDEPENDENT MEDICAL REVIEW MEDICAL NECESSITY BASIC STANDARD






WHEREAS, on 8/31/12, the California Legislature passed a new Workers’ Compensation 1 Reform Bill (SB863); and 2 3 WHEREAS, as part of the report Independent Medical Review has been established to resolve 4 UR denials; and 5 6 WHEREAS, decisions on medical necessity are based on Medical Treatment Utilization 7 Standards adopted by the Administrative Director of the Department of Workers’ Compensation 8 or other national guidelines; and 9 10 WHEREAS, treatment may be denied because national guidelines are silent on such treatment; 11 therefore be it 12 13 RESOLVED: That CMA supports a physician’s innovation and values his or her 14

professional experience over existing written guidelines, as long as his or her 15 practice is within the standard of care; and be it further 16

17 RESOLVED: That CMA work with legislators to amend the Labor Code by introducing the 18

following language: “Treatment may not be denied solely because it is not 19 discussed or specifically recommended in California Medical Treatment 20 Utilization Standards or any other national guidelines, but can only be denied 21 if care severely deviates from the standard.” 22

23 Current CMA Policy: 24 CMA supports the establishment of guidelines for utilization review, including appropriate protections for patients 25 and physicians. (HOD 501a-92) Additionally, CMA recognizes that utilization review or the determination of 26 medical necessity for health care covered services is different from engaging in the peer review process, and CMA 27 will work with the appropriate regulatory bodies to investigate inappropriate use of peer review laws to shield 28 medical necessity or utilization review decisions. (HOD D-2-10) 29 30 Fiscal Impact: 31 No cost to adopt as policy. If legislation is required, the potential cost is speculative and dependent on many 32 factors over which CMA has no control, such as the extent of external opposition or support for the proposal, 33 communications and commitment of resources by opponents and proponents. The cost of CMA sponsoring or 34 opposing a bill could be $95,000 or more; in individual legislative actions, costs can be much higher. Endorsement 35 or support of bills sponsored by others requires less effort and less cost. 36

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Resolution 413-13 TITLE: INDEPENDENT MEDICAL REVIEWER BASIC QUALIFICATIONS






WHEREAS, on 8/31/12, the California Legislature passed a new Workers’ Compensation 1 Reform Bill (SB863); and 2 3 WHEREAS, as part of the report Independent Medical Review has been established to resolve 4 UR denials; and 5 6 WHEREAS, no specific qualifications for reviewing physicians are set forth in the regulations; 7 and 8 9 WHEREAS, there is no requirement that the reviewer have any experience with the procedure 10 he is to make his opinion on; and 11 12 WHEREAS, frequently, the reviewer’s experience has nothing to do with a procedure he is to 13 review; therefore be it 14 15 RESOLVED: That CMA work with legislators to amend Labor Code Section 4610.6 by 16

introducing the following language: “The reviewer must be actively involved 17 in clinical practice and must have personal experience in his practice with the 18 procedure he is to review.” 19

20 Current CMA Policy: 21 CMA policy urges the Department of Healthcare Services to retain physicians and other advisory or consultant 22 personnel who are sufficiently well trained medically to responsibly review claims and requests for hospitalization 23 (HOD 205-80). 24 25 Fiscal Impact: 26 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 27 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 28 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 29 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 30 requires less effort and less cost. 31

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Resolution 414-13 TITLE: UTILIZATION REVIEW PHYSICIAN QUALIFICATIONS



Reference Committee D Endorsed by: District IV Delegation



WHEREAS, insurance companies perform utilization review (UR) to limit patients’ access to 1 medical care; and 2 3 WHEREAS, medical necessity is defined as community standard for medical care; and 4 5 WHEREAS, current law allows hiring physicians from out of California to perform UR; and 6 7 WHEREAS, frequently such physicians are not related by specialty or qualifications to the 8 treating physician; and 9 10 WHEREAS, AB 584 (Fong) was introduced to require all physicians performing UR in the 11 Workers’ Compensation arena to be licensed in California, but the bill was vetoed by the 12 Governor on 10/07/11, reasoning that no other commercial insurance has such limitation; 13 therefore be it 14 15 RESOLVED: That CMA support legislation requiring that any physician who performs 16

utilization review for medical treatment in California be licensed in 17 California and be in the same specialty and have the same qualifications as 18 the treating physician. 19

20 Current CMA Policy: 21 CMA supports the establishment of guidelines for utilization review, including appropriate protections for patients 22 and physicians. (HOD 501a-92) It is CMA policy that primary treating physicians in workers’ compensation 23 should be licensed in California. (HOD 408a-05) 24 25 Fiscal Impact: 26 The potential cost of legislative activity is speculative and dependent on many factors over which CMA has no 27 control, such as the extent of external opposition or support for the proposal, communications, and commitment of 28 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 29 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 30 requires less effort and less cost. 31

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Resolution 415-13 TITLE: PAYMENT FOR TREATMENT IN SETTLED WORKERS’ COMPENSATION LIEN CASES






WHEREAS, the main goal of implementation of SB863 was an attempt to minimize lien filing; 1 and 2 3 WHEREAS, there is no direct or indirect mechanism imposed by SB863 or any previous 4 “reform” to guarantee expedient payment to a provider, even when the treatment has been 5 approved, leaving lien litigation as the only practical method to collect appropriate payment; 6 and 7 8 WHEREAS, the language of Labor Code sections 3202.5 and 5705 force providers to litigate 9 anew, when the case-in-chief settles; and 10 11 WHEREAS, it places the lien claimant at a disadvantage by requiring the claimant to produce 12 the evidence of industrial injury, while the employee, who had direct knowledge of the events 13 and the employer who had an opportunity to investigate decline to produce such evidence and 14 instead elect to settle; therefore be it 15 16 RESOLVED: That CMA endorse and promulgate the concept that, when a patient’s 17

Workers’ Compensation case settles and the claimant receives compensation, 18 this denotes agreement among all parties that, in fact, an injury occurred; and 19 be it further 20

21 RESOLVED: That CMA endorse and promulgate the concept that among the parties 22

involved in a Workers’ Compensation case, agreement that an injury 23 occurred constitutes evidence of injury sufficient to meet the burden of proof 24 needed by a lien claimant who has been providing medical care to the injured 25 claimant in order to bill workers’ compensation insurance for services 26 rendered; and be it further 27

28 RESOLVED: That CMA work with legislators to amend the Labor Code by introducing the 29

following exception: “The burden of proof is met by the lien claimant, when 30 the employee and the employer chose to compromise.” 31

32 Current CMA Policy: 33 It is CMA policy to take an active role in eliminating the lien filing fees imposed on workers' compensation cases or 34 find an alternative means for physicians to have disputes resolved without using liens (HOD 423-12). 35 36


D 1 Fiscal Impact: 2 Costs to “endorse and promulgate” could be as high as $50,000. The potential cost of legislation is speculative and 3 dependent on many factors over which CMA has no control, such as the extent of external opposition or support for 4 the proposal, communications and commitment of resources by opponents and proponents. The cost of CMA 5 sponsoring or opposing a bill could be $95,000 or more; in individual legislative actions, costs can be much higher. 6 Endorsement or support of bills sponsored by others requires less effort and less cost. 7

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Resolution 416-13 TITLE: REIMBURSEMENT FOR SETTLED WORKERS’ COMPENSATION CASES






WHEREAS, a majority of denied cases in Workers Comp at the end either settle via C&R or 1 become awarded compensable after the trial; and 2 3 WHEREAS, no matter the outcome of the case-in-chief, the maximum reimbursement allowed 4 is Official Medical Fee Schedule; and 5 6 WHEREAS, litigating the lien costs much more money than treating an accepted case; and 7 8 WHEREAS, SB 457 (Calderon), which was approved by the Governor on 10/7/11, allows 9 payments to the private insurer, which paid for self-procured care, to be made at their C&U; 10 therefore be it 11 12 RESOLVED: That the CMA take an active role in changing the Labor Code to require 13

insurers to pay a physician’s usual and customary charges rather than the 14 contracted rates or the rates set by Department of Workers’ Compensation as 15 the maximum reimbursement rates, when the previously denied case either 16 settles via Compromise and Release or is awarded compensable by the judge. 17

18 Current CMA Policy: 19 None. 20 21 Fiscal Impact: 22 If legislation is required, the potential cost is speculative and dependent on many factors over which CMA has no 23 control, such as the extent of external opposition or support for the proposal, communications and commitment of 24 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 25 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 26 requires less effort and less cost. 27

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Resolution 417-13 TITLE: RENEWAL OF MEDICAL PROVIDER NETWORK MEMBERSHIP AGREEMENT

Author: Jeffrey Young, MD Contact: [email protected]

Introduced by: Jeffrey Young, MD

Reference Committee D Endorsed by: California Society of Physical Medicine and Rehabilitation



WHEREAS, physicians apply for inclusion to insurer medical provider networks; and 1 2 WHEREAS, the current practice of some medical providers networks is to include physicians 3 on the networks indefinitely; and 4 5 WHEREAS, physicians remain members of the network after a company is sold to another 6 entity or the physician has stopped practicing; and 7 8 WHEREAS, this will result in decreased patient access to medical care; and 9 10 WHEREAS, over time, this will result in physicians belonging to network they were unaware 11 of; therefore be it 12 13 RESOLVED: That CMA work to require medical provider networks to renew their 14

physician membership on a yearly basis; and be it further 15 16

RESOLVED: That this matter be referred for national action. 17 18 Current CMA Policy: 19 HOD 410-10 directed CMA to advocate that: (1) any contract by which any California licensed physician is 20 restrained from participating in any medical provider network (MPN) for Workers' Compensation is void; (2) 21 exclusion of California licensed physicians from any MPN for Workers' Compensation is a restraint of trade that 22 violates California Business and Professions Code section 1660; and (3) employers, third party administrators and 23 industrial carriers not be permitted to exclude any California licensed physicians from any MPN for Workers' 24 Compensation. BoT Min 07-31:10:13(4) reaffirmed CMA opposition to any attempts by insurers to force 25 physicians into MPNs without their knowledge and consent. 26 27 Fiscal Impact: 28 The potential cost of any legislative activity is speculative and dependent on many factors over which CMA has no 29 control, such as the extent of external opposition or support for the proposal, communications and commitment of 30 resources by opponents and proponents. The cost of CMA sponsoring or opposing a bill could be $95,000 or more; 31 in individual legislative actions, costs can be much higher. Endorsement or support of bills sponsored by others 32 requires less effort and less cost. 33

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Resolution 418-13 TITLE: RATE REGULATION FOR HEALTH INSURANCE PLANS

Author: Harrison Hines Contact: [email protected]

Introduced by: Medical Student Section




WHEREAS, health insurance rate increases from 2002 to 2012 have been significant for 1 families; premiums rose 97 percent while the general rate of inflation only increased 28 percent 2 and wages have only increased 33 percent; and 3 4 WHEREAS, Covered California has reported that premiums will be lower for individuals in 5 2014 than in 2013, but there is no estimate for subsequent years and no mention of regulations 6 on further increases in rates; and 7 8 WHEREAS, health insurers are increasing premiums in response to higher medical loss ratios 9 mandated by the Affordable Care Act; and 10 11 WHEREAS, the increase in health insurance rates will disproportionately burden the uninsured; 12 therefore be it 13 14 RESOLVED: That CMA study the effects of health plan rates on coverage to determine the 15

threshold at which coverage is excessively decreased due to increased 16 premiums; and be it further 17

18 RESOLVED: That CMA advocate for the development of a threshold above which 19

increases in existing health plan rates or the implementation of new rates 20 must be reviewed and approved by the California Legislature. 21

22 Current CMA Policy: 23 Longstanding CMA policy supports requiring health plans to fully disclose the percentage of premium dollars 24 expended on medical care. (HOD 911a-96) CMA supports the examination of all medical care insurance payment 25 programs and the development of recommendations to reduce the administrative costs of these programs and, 26 thereby, increase the proportion of the premium which is allocated to pay for patient care. (HOD 418a-89) 27 28 Fiscal Impact: 29 Indeterminate; potentially high costs due to actuarial and other studies that would be required. If CMA were to 30 undertake the advocacy that would be required, costs could be as high as $130,000 and is dependent on many 31 factors over which CMA has no control, such as the extent of external opposition or support for the proposal, 32 communications, and commitment of resources by opponents and proponents. 33

Report D-1-13 Reference Committee D 1 2

3 CALIFORNIA MEDICAL ASSOCIATION 4

HOUSE OF DELEGATES 5 6

October 11-13, 2013 7 8 9 TITLE: POLICY SUNSET REVIEW 10 11 Introduced by: Speaker of the House 12 Luther F. Cobb, MD 13 14 Author: Speaker of the House 15 16 17 Attached are the policies assigned to Reference Committee D for review pursuant to the 18 process adopted by the House of Delegates in Report C-10-04, “CMA Policy Review.” 19 The process provides that all House of Delegates policy presumptively terminates after 20 ten years unless specifically renewed by further action of the House, based on 21 recommendations of the relevant reference committee. 22 23 CMA staff renewal/non-renewal recommendations to the reference committee, based on 24 research of actions and developments subsequent to adoption ten years ago, are shown 25 beneath each policy. Reasons cited for non-renewal are those set forth in Report C-10-26 04. After hearing testimony and evaluating staff recommendations and any available 27 background information, the reference committee will recommend to the House of 28 Delegates whether the policies should be renewed or allowed to sunset. 29 30

It should be emphasized that policy reviewed is subject only to renewal or non-renewal 31 (termination). Accordingly, amendment of the reviewed policies is not in order. 32

Should a delegate wish to recommend renewal of a particular policy not recommended 33 for renewal by the reference committee, the policy review report of that reference 34 committee must be extracted when the committee’s report is presented to the House. 35 When the policy review report is being considered, an opportunity will be offered to then 36 extract an individual policy or policies for renewal. After adoption of the 37 recommendations concerning the remaining reviewed policies, the extracted policies will 38 be considered individually. Debate will be limited to the decision to renew or not renew 39 the particular policy. 40

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Report D-1-13 Attachment Page 1

POLICY SUNSET REVIEW:

POLICIES ASSIGNED TO REFERENCE COMMITTEE D Resolution 402-03 SINGLE ADDRESS FOR INSURANCE BILLING RESOLVED: That CMA support the following requirements: (1) that all payers maintain a single mail address for the submission of claims, (2) that this address be clearly printed on enrollees’ insurance cards, (3) that all payers maintain a single electronic address for receipt of claims, and (4) that payers notify physicians in advance of any changes to these addresses; and be it further RESOLVED: That health insurance companies providing health care benefits in California shall immediately enter all claims received from providers into their systems, assign a number to each claim received, and provide this information to the physician who submitted the claim; and be it further RESOLVED: That health plans be responsible for promptly routing claims to subcontracted payers. Renew.

* * * Resolution 404a-03 INSURANCE VERIFICATION FOR PAYMENT OF LABORATORY SERVICES RESOLVED: That laboratories and other providers of outpatient services be responsible for verification of insurance eligibility and authorization for services provided to patients; and be it further RESOLVED: That CMA oppose the imposition of any monetary penalty on a physician who in good faith refers a patient for laboratory or other outpatient services. Renew.

* * * Resolution 405a-03 FULL DISCLOSURE IN PPO CONTRACTS RESOLVED: That CMA support the requirement

that all payers who contract with physicians for health care services provide all necessary fee schedules, payment rules, and other information required for physicians to determine their reimbursement for each CPT code and any other service covered by the contract; and be it further RESOLVED: That CMA support the following requirements: (1) that all payers make available a copy of the executed contract to physicians within three business days of the request; (2) that all health plan EOBs contain documentation regarding the precise contract used for determining the reimbursement rate; (3) that once a year, all contracts must be made available for physician review at no cost; (4) that no contract may be changed without the physician's prior written authorization; and (5) that when a contract is terminated pursuant to the terms of the contract, the contract may not be used by any other payer; and be it further Renew.

* * * Resolution 410-03 INSURANCE COMPENSATION WHEN MEDICARE RATES ARE DECREASED RESOLVED: That CMA support legislation that prohibits insurance companies from decreasing their compensation rates for services provided to non-Medicare patients when Medicare rates are decreased; and be it further RESOLVED: That this matter be referred for national action. 1st Resolved: Renew. 2nd Resolved: Sunset – Resolutions that direct action based on prior CMA policy automatically sunset when the action has been carried out or is no longer required.

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Report D-1-13 Attachment Page 2 Resolution 413-03 WORKER’S COMPENSATION, NEGOTIATIONS, STATE ACTION EXEMPTION RESOLVED: That CMA consider legislation to create a board modeled after the Federal Reserve Board to address issues related to workers’ compensation, and that such board include representation from leaders in workers’ organizations, business, insurance and medicine; and be it further RESOLVED: That CMA reaffirm its commitment to legislation to create a state action exemption enabling physicians to negotiate rates and contract terms collectively with public and private payors. 1st Resolved: Renew. 2nd Resolved: Sunset – Resolutions that direct action based on prior CMA policy automatically sunset when the action has been carried out or is no longer required.

* * * Resolution 414-03 RBRVS AND WORKER’S COMPENSATION FEE SCHEDULE RESOLVED: That CMA oppose introduction of an unmodified RBRVS as the sole template for developing the new Official Medical Fee Schedule (OMFS) by the Administrative Director of the Division of Worker’s Compensation; and be it further RESOLVED: That CMA convene a workgroup of key stakeholders, including Specialty Society Representatives, to identify the necessary resources, develop a work plan, and explore the feasibility of creating a California Relative Value Unit Committee (RUC) to develop a new Workers’ Compensation Official Medical Fee Schedule (OMFS). 1st Resolved: Renew. 2nd Resolved: Sunset – Resolutions that direct action based on prior CMA policy automatically sunset when the action has been carried out or is no longer required.

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