August 2014

August 2014 • Vol. 36 No. 8

FRESNO COUNTY

KERN COUNTY

KINGS COUNTY

MADERA COUNTY

TULARE COUNTY

August 2014 • • VoVoVooVoV l. 36 No. 8l. 36 No. 8

Vital SignsVital SignsVital SignsVital SignsOfficial Magazine of

Fresno-Madera Medical Society

Kern County Medical Society

Kings County Medical Society


Tulare County Medical Society

See Inside:

“No” on Prop. 46Campaign

Renew Your Medical License Early

Small BusinessesReceive ExtendedDeadline for HealthInsurance Coverage

See Inside:

“No” on Prop. 46Campaign

Renew Your Medical License Early

Small BusinessesReceive ExtendedDeadline for HealthInsurance Coverage

August 2014 • Vol. 36 No. 8

2 AUGUST 2014 / VITAL SIGNS

S A N D I E G O

O R A N G E

L O S A N G E L E S

P A L O A L T O

S A C R A M E N T O

800-252-7706 www.CAPphysicians.com

Superior Physicians. Superior Protection.

For 35 years, the Cooperative of American Physicians, Inc. (CAP) has provided California’s finest physicians, like internal medicine specialist James Strebig, MD, with superior medical professional liability protection through its Mutual Protection Trust (MPT).

Physician owned and physician governed, CAP rewards excellence with remarkably low rates on medical professional liability coverage – up to 40 percent less than our competitors.

CAP members also enjoy a number of other valuable benefits, including comprehensive risk management programs, best-in-class legal defense, and a 24-hour CAP Cares physician hotline. And MPT is the nation’s only physician-owned medical professional liability provider rated A+ (Superior) by A.M. Best.

We invite you to join the nearly 12,000 preferred California physicians already enjoying the benefits of CAP membership.

We Celebrate Excellence

– James Strebig, MD CAP member, internal medicine physician, and former President of the Orange County Medical Association.

AUGUST 2014 / VITAL SIGNS 3

VitalSigns Contents

Official Publication of


Kings County Medical Society



August 2014Vol. 36 – Number 8

EditorAlan Birnbaum, MD

Managing EditorCarol Rau Yrulegui

Fresno-Madera Medical SocietyEditorial Board

Virgil M. Airola, MDHemant Dhingra, MDDavid N. Hadden, MDRoydon Steinke, MD

Kings RepresentativeTBD

Kern RepresentativeJohn L. Digges, MD

Tulare RepresentativeFrancine Hipskind

Calling all photographers:Please consider submitting one of your photographs for publication in Vital Signs. – Editorial Committee

Vital Signs is published monthly by Fresno-Madera Medical Society. Editorials and opinion pieces accepted for publication do not necessarily reflect the opinion of the Medical Society. All medical societies require authors to disclose any significant conflicts of interest in the text and/or footnotes of submitted materials. Questions regarding content should be directed to 559-224-4224, ext. 118.

Vital Signs SubscriptionsSubscriptions to Vital Signs are $24 per year. Payment is due in advance. Make checks payable to the Fresno-Madera Medical Society. To subscribe, mail your check and subscription request to: Vital Signs, Fresno-Madera Medi cal Society, PO Box 28337, Fresno, CA 93729-8337.

Advertising Contact:Display:

Annette Paxton,559-454-9331

[email protected]

Classified:Carol Rau Yrulegui

559-224-4224, ext. [email protected]

Cover Photograph: “Yosemite Falls in the Mist” By Ning Lin, OD, MD

CMA NEWS ...............................................................................................................................5

NEWS

CMA EDUCATION SERIES CALENDAR: August 2014 ..................................................................6

AFFORDABLE HEALTHCARE ACT: Surviving Covered California ....................................................7

HEALTHCARE REFORM ...........................................................................................................9

LEGISLATIVE NEWS: Unprecedented Number of Groups and Organizations Join Forces to Defeat Proposition 46 .....................................................................................10

CODING CORNER: Modifier 22: Reporting and Reimbursement ................................................11

CREDIT CARD UPDATE: Physicians Can Avoid High Credit Card Fees .........................................11

CLASSIFIEDS..........................................................................................................................19

FRESNO-MADERA MEDICAL SOCIETY .....................................................................................13

• President’s Message

• 2014 Physician Community Service Award Nomination Forms: Lifetime Achievement; Special Project or Service. Nominations due September 8, 2014

• Walk with a Doc

• Medical Manager’s Forum

KERN COUNTY MEDICAL SOCIETY ..........................................................................................17

• Medical Missionary Journey: Part One

TULARE COUNTY MEDICAL SOCIETY ......................................................................................18 • HIPPA and Your Vendors

• Walk With A Doc

• Upcoming Events

66660, Fresno (8/14)Full Size: 8.5" x 11" Bleed: .25’’ Live: 7.5” x 10”Folds to: na Perf: naColors: BWStock: naPostage: naMisc: naM

ERCER

Let us help find the right Long-Term Care insurance plan for you, so you can spend time on things that matter the most.

People are living longer these days, but as life expectancies increase, so does

the risk of serious health problems that could require long-term care. In fact,

at retirement age, 70% of Americans will need long-term care and 35% will

enter a nursing home.1 And with the average cost for nursing home care in a

private room equating to more than $87,600 per year, that could literally cost

most or all of your life’s savings.2

Long-Term Care insurance may not be for everyone. But with soaring health

care costs, insurance restrictions and the need to stretch retirement savings

through more years . . . it’s a good idea to seriously consider this valuable

coverage while receiving a member premium discount.

To learn more about how FMMS, KCMS and TCMS members can help protect their assets from the rising cost of long-term care, call us or go online today.

Call 800.616.8759 or visit www.myltcplan.com/fmms.

Long-Term CareResourcesFMMS, KCMS and TCMS are pleased to announce that members now have access to an interactive and educational Long-Term Care evaluation tool to help you make the best decisions for your specific situation. To learn more, visit: www.myltcplan.com/fmms.

We work to protect it.We work to protect it.You create a brighter future.

1Department of Health and Human Services, www.longtermcare.gov/the-basics/how-much-care-will-you-need/, viewed April 1, 2014.2Genworth 2013 Cost of Care Survey, March 2013, https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.htmlThe Long-Term Care Resources Network is only available for residents of the United States. Coverage may vary or may not be available in all states.

66660 (8/14) Copyright 2014 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017800-842-3761 • [email protected] • www.CountyCMAMemberInsurance.com

CA Ins. Lic. #0G39709 • Mercer Health & Benefits Insurance Services LLC

Sponsored by:

FRESNO-MADERA MEDICAL SOCIETY

KERN COUNTY MEDICAL SOCIETY

TULARE COUNTY MEDICAL SOCIETY


66660, Fresno (8/14)Full Size: 8.5" x 11" Bleed: .25’’ Live: 7.5” x 10”Folds to: na Perf: naColors: BWStock: naPostage: naMisc: naM

ERCER

Let us help find the right Long-Term Care insurance plan for you, so you can spend time on things that matter the most.

People are living longer these days, but as life expectancies increase, so does

the risk of serious health problems that could require long-term care. In fact,

at retirement age, 70% of Americans will need long-term care and 35% will

enter a nursing home.1 And with the average cost for nursing home care in a

private room equating to more than $87,600 per year, that could literally cost

most or all of your life’s savings.2

Long-Term Care insurance may not be for everyone. But with soaring health

care costs, insurance restrictions and the need to stretch retirement savings

through more years . . . it’s a good idea to seriously consider this valuable

coverage while receiving a member premium discount.

To learn more about how FMMS, KCMS and TCMS members can help protect their assets from the rising cost of long-term care, call us or go online today.

Call 800.616.8759 or visit www.myltcplan.com/fmms.

Long-Term CareResourcesFMMS, KCMS and TCMS are pleased to announce that members now have access to an interactive and educational Long-Term Care evaluation tool to help you make the best decisions for your specific situation. To learn more, visit: www.myltcplan.com/fmms.

We work to protect it.You create a brighter future.

1Department of Health and Human Services, www.longtermcare.gov/the-basics/how-much-care-will-you-need/, viewed April 1, 2014.2Genworth 2013 Cost of Care Survey, March 2013, https://www.genworth.com/corporate/about-genworth/industry-expertise/cost-of-care.htmlThe Long-Term Care Resources Network is only available for residents of the United States. Coverage may vary or may not be available in all states.

66660 (8/14) Copyright 2014 Mercer LLC. All rights reserved. 777 South Figueroa Street, Los Angeles, CA 90017800-842-3761 • [email protected] • www.CountyCMAMemberInsurance.com

CA Ins. Lic. #0G39709 • Mercer Health & Benefits Insurance Services LLC

Sponsored by:

FRESNO-MADERA MEDICAL SOCIETY

KERN COUNTY MEDICAL SOCIETY

TULARE COUNTY MEDICAL SOCIETY

CMA NEWSPROVIDER ACCESS ISSUES PLAGUE ANTHEM AND BLUE SHIELD AS DMHC BEGINS INVESTIGATION

The Department of Managed Health Care (DMHC) began conducting a “non-routine audit” of Anthem Blue Cross and Blue Shield of California to investigate the accuracy of the plans’ provider directories and identify whether either plan violated any network adequacy laws. According to the DMHC, consumer complaints about access issues for both plans prompted the investigation.

Blue Cross and Blue Shield are the only two exchange plans using narrowed provider networks for their exchange and “mirror” products. �e state is looking at whether the networks are too narrow in some counties, making it di�cult for enrollees to �nd participating providers.

A California Medical Association (CMA) survey of California physicians found that there is also widespread confusion about exchange plans contracting amongst providers, with 80 percent of physicians stating they had been confused about their participation status.

Health plans o�en use intentionally vague or confusing contracting practices, which result in consumer confusion and frustration, as physicians o�en do not know that they are listed as participating in certain networks. With roughly 1.4 million Californians newly enrolled in Covered California products since January, it has been di�cult for both physicians and patients to identify who is in and who is out of the narrow provider networks.

CMA has urged Covered California to address this and other issues before the next open enrollment period.

As part of the audit, DMHC has hired pmpm Consulting to contact practices to ask about their participation status with the two plans. If contacted by pmpm Consulting, CMA strongly encourages the practice to respond to their questions. �is is an investigation into the accuracy of the plan directories and whether the plans have violated any laws, not an investigation of physician practices. DMHC expects to complete its investigation in approximately 60 days. Findings of the survey will be released publicly prior to the next Covered California open enrollment period, which is scheduled for November 15.

Having trouble �nding an in-network provider or facility?Patients who are having trouble �nding an in-network physician or

facility are encouraged to contact the DMHC Help Center at 888-466-2219 for assistance or for complaints.

We also ask that physicians notify CMA if they are experiencing di�culties �nding in-network providers to whom they can refer patients so that we may raise the issue with the plan, Covered California and the appropriate regulator. Contact CMA’s reimbursement helpline at 888- 401-5911 or [email protected].

RENEW EARLY! PHYSICIANS RENEWING LICENSES EXPERIENCING DELAYS

The Medical Board of California is asking physicians who need to renew their medical licenses to do so early due to delays associated with the implementation of a new online licensing and enforcement system. Renewal notices are sent out 90 days in advance of the licensee’s expiration date.

�is transition is resulting in disruptions in cashiering and other services and is a�ecting both online and mail renewals. Currently, the medical board is experiencing delays of 6-8 weeks to update its website and provide physicians with a current wallet license.

If you have not yet submi�ed your renewal application to the medical board, do not submit it to the P.O. Box listed on the renewal notice, as it may not be processed prior to your expiration date. For faster service, the medical board recommends submi�ing the renewal application to: Medical Board

of California; 2005 Evergreen Street, Suite 1200; Sacramento, CA 95815�is will allow for expedited processing. Questions should be directed

to the medical board at 916-263-2382 or [email protected].

CMA RELEASES 2014 ANNOTATED MODEL MEDICAL STAFF BYLAWS

The California Medical Association (CMA) has released its 2014 Model Medical Sta� Bylaws. �ese bylaws are the de�nitive guide for medical sta�s, providing details on professional and legal structures to support e�ective medical sta� operations and self-governance.

�e model bylaws are fully annotated to provide background information on critical provisions, including explanations of relevant state and federal laws, hospital accreditation standards, and other explanatory information. CMA’s lawyers performed a complete evaluation of the bylaws to ensure they comport with current law and re�ect CMA’s positions and policies.

New for 2014: �e California Supreme Court has recently decided two cases having a direct e�ect on medical sta�s and hospital-based physicians. El-A�ar v. Hollywood Presbyterian Medical Center addresses the balance of power and responsibilities between hospitals and medical sta�s and the individual rights of physicians in peer review. Fahlen v. Su�er Central Valley Hospitals addresses the interplay between peer review and whistleblower protections for physicians. Many other opinions by the intermediate appellate courts (which also establish binding law through the state) were handed down last year having a signi�cant impact on physician and medical sta� rights in hospitals. All of these cases, as well as changes to Joint Commission standards and other authorities, are discussed throughout the footnotes to the CMA model bylaws.

�e 2014 Model Medical Sta� Bylaws are available free to any medical sta� with an active membership in CMA’s Organized Medical Sta� Section (OMSS). If your medical sta� is not already an OMSS member, you can join by completing and submi�ing the OMSS membership application at www.cmanet.org/omss.

�e model bylaws are also available to non-OMSS members for a fee. For more information, visit CMA’s online resource library.

Contact: CMA member help center, 800-786-4262 or member [email protected].

PROBLEMS GETTING PAID?

The California Medical Association’s Center for Economic Services provides direct reimbursement assistance to CMA physician members and their o�ce sta�.

Reimbursement Help Line: 88-401-5911; or [email protected] .

When to call CMA?CMA members can call on CMA’s practice management experts for

free one-on-one help with contracting, billing, and payment problems. If you answer “yes” to any of the following questions, it might be time to call for help.

• Are your claims not being paid in a timely manner?• Are you not being paid according to your contract?• Are your claims being denied a�er obtaining prior authorization or

verifying eligibility?• Are you receiving unreasonable requests for medical records or

untimely requests for refunds?• Are you having di�culty obtaining fee schedules and/or payment

rules?


KERN

FAMILY MEDICINE FACULTY

Clinica Sierra Vista is seeking a Board Certi ed Family Medicine Physician to serve as faculty for the Rio Bravo Family Medicine Residency Program. Full and part-time teaching positions available! Make a di�erence in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary o�ered.

Federal loan forgiveness may be available for quali ed applicants.

FRESNO

FAMILY MEDICINE FACULTY

Clinica Sierra Vista is seeking a Board Certi ed Family Medicine Physician to serve as faculty for the Sierra Vista Family Medicine Residency Program. Full and part-time teaching positions available! Make a di�erence in the lives of new physicians and join our faculty! Inpatient and Obstetrics a plus! Competitive salary o�ered.

Federal loan forgiveness may be available for quali ed applicants.

New Career OpportunitiesAvailable

Interested applicants may contactClinica Sierra Vista

(661) 979-0812

You said what to the Medical Board’s investigator?Physicians often come to us after they have been interviewed by a Medical Board investigator or after they have already provided a written description of their care.

Did you know that a Medical Board investigator is a sworn peace officer, with a gun, and a badge, and the power to arrest you?

When the Medical Board demands an explanation, seek help immediately. The attorneys at Baker, Manock & Jensen have helped many physicians through the maze that is a Medical Board investigation. We would be honored to help you.

George L. Strasser5260 North Palm Avenue

Fresno, CA 93704559 432-5400

[email protected]

EDUCATION SERIES2014

CMA Center for Economic Services Webinars At-A-Glance

Most webinars are FREE for CMA members and their staff,

$99 for non-members.

A Webinar Invitation for All Physicians and Their Staff

The California Medical Association (CMA) offers programs to educate physicians and staff on a range of practice management issues. Space is limited, so register soon.

Workers’ Compensation AdvancedPart 1: August 5 • 12:15-1:15pm: Tips and Tricks for Workers’ Compensation BillingDaisyBill presents this series covers specific advanced topics for those physicians who already treat injured workers. DaisyBill electronically manages thousands of workers’’ comp bills each month. More importantly, we capture granular payment data about these bills. Using our extensive data analysis these webinars will focus on known strategies that will increase revenue, decrease costs, and get these bills paid quickly. In this webinar, attendees will learn about the most common billing errors to avoid when billing workers’ compensation. This webinar will review five tips to immediately increase workers’ comp revenue and the new RBRVS billing rules and reimbursements.

Part 2: August 12 • 12:15-1:15pm; Second Bill Review Plus Managing Third Party Billers

In this webinar, attendees will learn about five essential components of a compliant Second Bill Review. This webinar will also review easy ways to make sure your third party biller is correctly managing your workers’ comp bills.

Part 3: August 19 • 12:15-1:15pm; Requests for Authorization, Dis-pensed Pharmaceutical and DME-POS billing for workers’ comp

In this webinar, attendees will learn how to correctly submit Request for Authorizations and how to bill for dispensed pharmaceuticals and DMEPOS.

These webinars are hosted by the California Medical Association. You must register at least one hour prior to the event. Once your registration has been approved, you will be sent an email confirmation with details on how to join the webinar. Questions? Call the CMA Help Line at 800-786-4262.

CMA NEWS


are sold outside of Covered California but utilize the narrowed exchange provider networks? Practices must review patient ID cards and eligibility information closely to identify whether the practice is in or out of network for that particular plan. Every plan o�ered in the exchange must also be o�ered outside of the exchange, using the same provider network. Confusion around these o�-exchange products, also called “mirror” products, has resulted in a number of practices unknowingly seeing patients out-of-network for products that use a narrowed exchange provider network, as these ID cards will not have the Covered California logo. �e issue is speci�c to just Anthem Blue Cross and Blue Shield of California, because they are the only two plans o�ering narrowed networks.

Blue Shield mirror products (bought o� of the exchange but utilizing the ex-change provider network) will list one of the fol-lowing product names on the pa-tient ID card:

• Basic PPO/EPO• Enhanced PPO/EPO• Get Covered PPO/EPO• Preferred PPO/EPO• Ultimate PPO/EPO.Anthem Blue Cross mirror products (bought o� of the exchange but

utilizing the exchange provider network) will list “Pathway” (network name) on the bo�om of the card. �e product names for mirror products, which appear on the top of the ID card are:

• Anthem Core DirectAccess (EPO/PPO)• Anthem Essential DirectAccess (EPO/PPO)• Anthem

Essential Guided Access (HMO)

• Anthem Preferred DirectAc-cess (EPO/PPO)

• Anthem Premier DirectAccess (EPO/PPO)

• Anthem Premier Guided Access (HMO)If you see these product or network names on the Anthem Blue Cross

or Blue Shield of California patient ID cards, it indicates the patient only has access to the narrowed exchange network. Again, these are the only two plans currently o�ering narrowed networks. �e other nine plans generally o�er their full network to exchange and mirror product patients.

AFFORDABLE HEALTHCARE ACT

Editor’s Note: Due to a printing error in last month’s Vital Signs, a portion of this article was not printed. �is month the article is reprinted in its entirely.

Covered California reports that nearly 1.4 million individuals have enrolled in exchange plans, which signi�cantly surpasses original targets, making it critical that physicians and their sta� know what to expect from these products. To help answer some of the more common questions, the California Medical Association (CMA) o�ers this information to assist physician practices in surviving this major change in health care.

How can I identify whether an exchange patient is in months two or three of the grace period? Enrollees who receive federal premium subsidies to help pay their premiums are entitled to keep their insurance for three months a�er they have stopped paying their premiums. Insurance ID cards for exchange enrollees do not indicate whether the enrollee is subsidized. Current enrollment trends, however, predict that 88 percent of those with exchange coverage will be subsidized and receive the three-month grace period. In other words, those with a Covered California logo on the ID card will most likely will have the three-month grace period.

In the �rst 30 days of the grace period, federal law requires plans to pay for services incurred, but in months two and three of the grace period plans can pend and deny claims. So it will be extremely important that practices verify eligibility on all exchange patients, ideally on the date of service, or as near the time of service as possible. If the patient is in months two or three of the grace period, the health plan should indicate that coverage is inactive or otherwise suspended.

CMA queried Anthem Blue Cross, Blue Shield of California and Health Net, which account for approximately 75 percent of the total Covered California enrollees, on exactly what to look for in eligibility veri�cation to identify patients who are in months two and three of the grace period. �ey report the following:Plan Name Grace Period Eligibility Status Indicator

(Days 31-90 of grace period)

Anthem Blue Cross Inactive pending investigationBlue Shield of California PendedHealth Net Eligibility suspended

Unsubsidized exchange patients and those with a mirror product are not entitled to the 90-day federal grace period, rather they only receive the 30-day grace period called for under state law.

What are my options if a patient presents with inactive coverage on account of the grace period? Practices should have policies in place regarding how they will handle patients who are in months two or three of the grace period. Patients should ideally be made aware of this policy in advance. If a patient’s eligibility veri�cation comes back indicating his or her coverage is not active, the practice should treat the situation as they would any other patient who has had a lapse in coverage. For non -emergent services, patients may be given the option to either pay cash at the time of service or reschedule to a later date when their coverage is e�ective. �e o�ce policy should include how patients will be triaged to determine whether their condition is emergent or urgent and the policy should be approved by the physician.

How can I identify the o�-exchange, or “mirror,” products that

Surviving Covered CaliforniaProvided by California Medical Association

Please see next page

Sample Blue Shield ID Card

Sample Anthem Blue Cross ID Card


Covered CaliforniaContinued �om page 7

Given the confusion and varying product/net-work names, CMA submi�ed a le�er to Peter Lee, Executive Director of Covered California, and the Exchange Board of Directors, recommending Covered California develop new requirements of plans to clearly identify mirror products on pa-tient ID cards, among other things.

What options are available for Covered California/mirror product patients who are having trouble �nding in-network providers and/or facilities to provide care?CMA has received a number of complaints about patient access to care issues, mainly in the narrowed networks o�ered by Anthem Blue Cross and Blue Shield of California. In fact, in a recent CMA survey of physicians’ experiences with exchange plans, more than half of physician respondents indicated that they have experienced di�culties �nding an in-network physician or hospital to which they can refer their Covered California patients.

Patients who are having trouble �nding an in-network physician or facility are encouraged to �le a complaint with the Department of Managed Health Care’s Help Center at 888-466-2219. When calling, patients should indicate they have a Covered California plan and cannot �nd an in-network physician/facility that is reasonably accessible.

In addition to contacting the health plan, we ask that physicians and practice sta� who are experiencing di�culties �nding in-network providers notify CMA of the issue so that we may raise it with Covered California and the appropriate regulator. Issues may be submi�ed to our physician helpline at 888-401-5911 or [email protected].

Still have questions? Visit CMA’s exchange resource center at www.cmanet.org/exchange. At the resource center, you may download CMA’s comprehensive exchange toolkit, “CMA’s Got You Covered: A Physician’s Guide to Covered California, the state’s health bene�t exchange,” as well as a other CMA exchange resources. CMA members and their sta� also have FREE access to our reimbursement helpline at 888-401-5911 or [email protected].


HEALTHCARE REFORMBROWN SIGNS BILL DELAYING ACA DEADLINE FOR SMALL BUSINESSES

Gov. Jerry Brown (D) signed into law a bill (SB 1446) that will give state businesses with fewer than 50 employees an extra year (2015) to obtain health coverage that complies with A�ordable Care Act requirements, the Sacramento Business Journal reports.

�e measure takes e�ect immediately and allows small businesses to renew coverage at any point in the year (Robertson, Sacramento Business Journal, 7/7).

Under the ACA, all health plans must include 10 essential benefits, including hospitalization, prescription drugs, maternity care and mental health treatments (O’Neill, “KPCC News,” KPCC, 7/7).

�e law’s employer mandate provision states that any health plans that do not meet all 10 requirements will be canceled at the end of 2014.

SB 1446 was introduced by Sen. Mark DeSaulnier (D-Concord). State Insurance Commissioner Dave Jones (D) and the California Department of Insurance also sponsored the measure.

ANTHEM MISLED MILLIONS ABOUT HEALTH PLAN NETWORKS, LAWSUIT ALLEGES

Last month, Consumer Watchdog �led a class-action lawsuit alleging that Anthem Blue Cross misled “millions” of consumers who enrolled in its health plans about which physicians and hospitals were included in their provider networks, Kaiser Health News reports.

Consumer Watchdog �led the lawsuit on the behalf of all Anthem members who purchased individual coverage through the state health

insurance exchange or directly from the insurer between Oct. 1, 2013, and March 31.

Speci�cally, the lawsuit alleges that Anthem:

• Delayed giving its customers complete information until it was too late for them to switch their coverage choice;

• Did not inform its customers that it no longer o�ered out-of-network coverage in four of state’s largest counties -- Los Angeles, Orange, San Diego and San Francisco; and

• Misled or did not inform its customers about which doctors and hospitals were participating in the insurer’s new plans.

As a result of those alleged failures, the lawsuit states that many members received thousands of dollars in unexpected medical bills and were unable to see their preferred physician.

Jerry Flanagan, lead sta� a�orney at Consumer Watchdog, said Anthem “intentionally misrepresented and concealed the limitations of their plans because it wanted a big market share.”

Anthem’s ResponseAnthem spokesperson Darrel Ng declined to comment directly on

the lawsuit but said Anthem will pay the claims of members who received treatment from falsely listed physicians during the �rst three months of 2014.

However, he said the insurer would not extend that policy for members who found out a�er March 31 that their longtime doctors were not included in their plan’s network (Appleby, Kaiser Health News, 7/9).


LEGISLATIVE NEWS

oPPoNENtS oF ProP. 46Coalition List and numbers (as of July 15, 2014):

Doctors and Health Groups ................................... 83Community Clinics & Health Centers ....... 960Hospitals ............................................................................. 97County Medical and Dental Societies ............. 53Medical and Dental Groups .................................115

In addition to the above Health-Related groups and organizations:

Labor Unions & Healthcare TrustsService Employees International Union

(SEIU) CaliforniaInternational Brotherhood of BoilermakersAFSCME California PEOPLEIBEW Ninth DistrictSEIU United Long Term Care Workers

(ULTCW)SEIU-USW W (United Security Workers

West)SEIU 1000Committee of Interns and Residents-SEIUIBEW Local 11IBEW Local Union 441IBEW Local Union 477IBEW Local Union 551Union of American Physicians and Dentists

(AFSCME Local 206)Southern California Pipe Trades Health &

Welfare FundBoilermakers Local 92Boilermakers Local 1998Plumbers & Pipefitters Local Union 228Plumbers & Steamfitters Local Union 398Plumbers and Pipefitters UA Local Union 442Plumbers & Pipefitters Local 447Plumbers, Pipe and Refrigeration Fitters UA

Local 246Sheet Metal, Air, Rail and Transportation

Workers (SMART), Sheet Metal Workers’ Local Union No. 104

Southern CA Pipe Trades DC 16Sprinkler Fitters UA Local 483

Civil Liberties GroupsAmerican Civil Liberties Union of CaliforniaAmerican Civil Liberties Union, Northern

CaliforniaAmerican Civil Liberties Union of Southern

CaliforniaAmerican Civil Liberties Union of San Diego

and Imperial Counties

unprecedented Number of groups and organizations Join Forces to Defeat Prop. 46:

The Ballot Initiative to Raise the MICRA CapWhen was the last time you saw this mix of a group come together for a cause?

Education GroupsCalifornia Teachers AssociationCalifornia School Boards AssociationCalifornia Association of School Business

OfficialsCalifornia School-Based Health AllianceSmall School Districts’ Association

Children’s GroupsChildren’s Specialty Care CoalitionCalifornia Children’s Hospital AssociationChildren’s Physicians Medical GroupMiller Children’s Hospital Long BeachA New PATH (Parents for Addiction

Treatment & Healing)PADRES Contra El CancerSouth Bay Children’s Health CenterTotally Kids Specialty Healthcare

Ethnic GroupsAngel City Dental SocietyArmenian American Medical SocietyArmenian Dental SocietyArab American Dental AssociationCalifornia Black Chamber of CommerceCalifornia Hispanic Chambers of CommerceHispanic Dental Association San Diego

Binational ChapterIndian Dental AssociationIranian Dental AssociationLatino Physicians of CaliforniaNetwork of Ethnic Physician OrganizationsPhilippine Medical Society of Northern

CaliforniaSacramento Hispanic Chamber of CommerceSolano County Black Chamber of CommerceSouthern CA Filipino Dental Society

Professional Liability CarriersThe Doctors CompanyCAP Physicians Insurance Agency, IncCooperative of American PhysiciansNORCAL Mutual Insurance CompanyCalifornia Healthcare Insurance Company,

Inc., RRGBETA Healthcare GroupMedical Insurance Exchange of CaliforniaThe Mutual RRG, IncPhysicians Reimbursement Fund, RRGPodiatry Insurance Company of America

(PICA)Prevail Insurance Management ServicesThe MutualThe Dentists Insurance CompanyOphthalmic Mutual Insurance CompanyFireman’s Fund Insurance Company

Business & Taxpayer GroupsCalifornia Chamber of CommerceBay Area CouncilValley Industry & Commerce AssociationSan Diego Regional Chamber of CommerceSouthwest California Legislative CouncilBig Bear Chamber of CommerceElk Grove Chamber of CommerceOxnard Chamber of CommercePlacer County Taxpayers AssociationTorrance Area Chamber of CommerceSanta Clarita Valley Chamber of CommerceChula Vista Chamber of CommerceHuntington Beach Chamber of CommerceCorona Chamber of CommerceThe Chamber of Commerce of the Santa

Barbara RegionGreater Bakersfield Chamber of CommerceCamarillo Chamber of CommerceInland Empire Taxpayers AssociationNorth Orange County Legislative AllianceFullerton Chamber of CommerceLos Angeles Area Chamber of CommerceSantee Chamber of CommerceLa Canada Flintridge Chamber of Commerce

& Community AssociationSanta Monica Chamber of CommerceCalifornia Taxpayer Protection CommitteeGreater Fresno Area Chamber of CommerceVentura Chamber of Commerce

SeniorsAltaMed Health Services CorporationCurry Senior Center

Civil JusticeCalifornia Citizens Against Lawsuit AbuseCivil Justice Association of California

Local GovernmentsCity of Long BeachCalifornia State Association of Counties

Excess Insurance Authority

ProPoNENtS oF ProP. 46U.S. Senator Barbara BoxerConsumer WatchdogConsumer Attorneys of California (formerly California Trial Lawyers

Association)


CODING CORNER CREDIT CARD UPDATE

Modifier 22: Reporting and ReimbursementCPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating speci�cally to physician billing. �is month’s tip comes �om G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

CPT® modi�er 22 increased procedural services allows a provider to gain additional reimbursement for an unusually di�cult or time-consuming procedure. To realize that extra payment, your billing sta� will have to make a special e�ort, as well.

Per CPT® Appendix A, modi�er 22 may be appended to a CPT® code to indicate that the work performed was “substantially greater than typically required…. ” CPT® does not de�ne a “substantially greater” e�ort, although some payors do o�er guidelines (e.g., the e�ort and/or time to perform the procedure should be “at least 25 percent greater than usual”). Regardless of payor, you should append modi�er 22 infrequently, and for only the most unusual procedures.

Speci�c circumstances that may call for modi�er 22 include:• Intra-operative hemorrhage resulting in a signi�cant amount of increased operative

time.• Emergency situations that require signi�cant e�ort beyond the normal service. �is

does not include minor intra-operative complications that sometimes occur.• Abnormal pathology, anatomy, tumors and/or malformations that directly and

signi�cantly interfere with the normal progression of a procedure.Also, keep in mind these caveats:• Additional time, by itself, does not justify the use of modifier 22.• Do not use modifier 22 when the existing CPT® code describes the service.• Do not use modi�er 22 to indicate that a specialist (no ma�er how specialized)

performed the service.• Do not use modi�er 22 if the complication is due to the surgeon’s choice of surgical

approach.

CPT® guidelines require that provider documentation support “the substantial additional work and the reason for the additional work (i.e., increased intensity, time, technical di�culty of the procedure, severity of patient’s condition, physical and mental e�ort required).” �e provider should explain and identify additional diagnoses, pre-existing conditions, or unexpected �ndings or complicating factors that contributed to the extra time and e�ort.

Use comparisons to clarify how the procedure differed, using quantifiable criteria. For example: �e patient lost 800 cc’s of blood, rather than the usual 100-200 cc’s lost during a procedure of the same type. Time is also quanti�able (e.g., “the surgery took four hours instead of the usual 1½-2 hours”).

Payors may request a full operative report to verify the unusual nature of the coded procedure. Because most claims are now sent electronically, you should include comments in the narrative �eld, using everyday language, to explain precisely why (and how much) additional e�ort and/or time were required to complete the procedure, along with the statement, “Request documentation if needed.” If the payer requests the additional details, be prepared to send the full operative note, along with a cover le�er (with provider signature) detailing the unusual nature of the procedure.

�e Centers for Medicare & Medicaid Services and other payers scrutinize modi�er 22 claims, and primary payor claims submi�ed with a 22 modi�er are o�en subject to a full medical review. If your claim is correctly coded and well supported by documentation, be persistent in pursuing payment.

Lastly, when submi�ing your claim with modi�er 22, you have to ask for additional payment. Payors won’t automatically increase reimbursement. Instead, you should recommend an appropriate fee. For instance, if a surgical procedure takes twice as long due to unusual clinical circumstances, you could ask the payor to increase the intra-operative portion of the payment by 50 percent.

Physicians Can Avoid High Virtual Credit Card FeesIf your practice accepts virtual credit card (VCC) payments from health plans, you may be losing a signi�cant amount of your contractual payments to high interchange fees. Fortunately, there are steps you can take to stop paying unnecessary charges.

To disburse claims payments, health plans have increasingly shi�ed from paper checks to electronic payment methods, including payer-issued VCCs. With this method, a health plan sends credit card payment instructions to physicians, who process the payments using standard credit card technology.

�is method is bene�cial to health plans, but costly for physicians. Health plans o�en receive cash-back incentives from credit card companies for VCC transactions. Meanwhile, VCC payments are subject to transaction and interchange fees, which are born by the physician practice and can run as high as 5 percent per transaction for physician practices.

Here are three helpful steps to minimize fees:Register for electronic funds transfer (EFT)

payments. �e Health Insurance Portability and Accountability Act (HIPA A) requires all health plans to o�er standardized EFT using the Automated Clearinghouse (ACH) Network. Similar to direct deposit, ACH EFT allows health plan payments to be directly paid into a physician’s designated bank account. Each ACH EFT transaction carries only one fee of about 34 cents, far less than the potential 5 percent fee charged to VCC transactions. In order to receive ACH EFT, physicians should request and register for this payment method with payors.

Be aware of restrictions in payment methods when contracting with health plans. Even though HIPA A requires health plans to make EFT payments available upon request, health plans may try to require other payment methods, such as VCC, within their contracts with physicians. Be cognizant of any such restrictions and avoid signing contracts with in�exible payment terms.

Educate your practice sta�. If your practice sta� processes both patient and health plan payments, make sure they know how to di�erentiate between patient and health plan credit card payments to avoid authorization of VCC payments from health plans.

�e American Medical Association (AMA) EFT toolkit has more information on EFT payment, including a VCC tip sheet, “�e e�ect of health plan virtual credit card payments on physician practices” (free AMA login required) with more information on avoiding high fees.

For more information contact EFT at 888-401-5911 or [email protected].

12 AUGUST 2014 / VITAL SIGNS12 AUGUST 2014 / VITAL SIGNS

65457, Fresno, (7/14)Full Size: 8.5” x 11” Bleed: 8.75” x 11.25” Live: 7.5” x 10”Folds to: N/A Perf: N/AColors: 1c=(Black) Stock: N/A Postage: N/A Misc: N/AM

ERCE

R

A former employee sued me for wrongful termination.

For more information on these important benefits, and the special FMMS, KCMS and TCMS First-Time Buyers Program, please contact Mercer at:

800-842-3761

or email us at [email protected]

Sponsored by:

65457 (7/14) Copyright 2014 Mercer LLC. All rights reserved. • 777 S. Figueroa St., Los Angeles, CA 90017 www.CountyCMAMemberInsurance.com • [email protected]

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • 800-842-3761

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. FMMS, KCMS and TCMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are:

A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim.

Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

EEO compliance training for managers/supervisors. An internet-based training program, compliant with California law, provides supervisors with sexual harassment training.

Optional Wage and Hour Defense Coverage. (Subject to additional premium.)

Ask about our First-Time Buyers Program.





Fresno-Madera

Post O�ce Box 28337 Fresno, CA 93729-8337

1040 E. Herndon Ave #101 Fresno, CA 93720

559-224-4224 Fax 559-224-0276

website: www.fmms.org

O�cers Prahalad Jajodia, MD

PresidentA.M. Aminian, MD

President-ElectHemant Dhingra, MD

Vice PresidentAhmad Emami, MD Secretary/Treasurer

Ranjit Rajpal, MD Past President

Board of Governors Alan Birnbaum, MD

S.P. Dhillon, MD William Ebbeling, MD

Anna Marie Gonzalez, MD David Hadden, MD

Joseph B. Hawkins, MD Sergio Ilic, MD

Alan Kelton, MC Constantine Michas, MD

Trilok Puniani, MD Khalid Rauf, MD

Roydon Steinke, MD

CMA Delegates FMMS President Don Gaede, MD

Michael Gen, MD Brent Kane, MD

Brent Lanier, MD Kevin Luu, MD

Andre Minuth, MD Roydon Steinke, MD Toussaint Streat, MD

CMA Alternate Delegates FMMS President-Elect Perminder Bhatia, MD Praveen Buddiga, MD

Surinder P. Dhillon, MD Trilok Puniani, MD Oscar Sablan, MD

CMA Trustee District VI Virgil Airola, MD

Sta� Sandi Palumbo

Executive Director

IT’S OFFICIAL: NO ON 46 CAMPAIGN

Following last month’s Secretary of State’s assignment of proposition numbers to quali�ed ballot measures, the MIC� ballot initiative campaign is now o�cially being referred to as the “ NO on Prop 46” campaign. With a proposition number assigned, the measure is now much more visible to potential voters, meaning that the public will be hearing more from both the proponents and opponents between now and Election Day – November 4, 2014.

�ere is a growing coalition dedicated to defeating this Trial Lawyers’ MIC� lawsuit measure. See page 10 of this issue to see how diverse this coalition is – but most importantly – notice the very limited number of proponents. Talk about special interests! �at alone should raise voters’ suspicions on the merits of this proposition.

Voters – and our patients – need to be made aware of this deceptive proposition – that its intent is to put more money (and lawsuits) into the pockets of the trial a�orneys. It’s not to curb drug abuse among doctors and other health care professionals.

In fact, the authors of this proposal have been quoted as saying that the drug-testing part was thrown in as the “ultimate sweetener.” �is is a perfect example of special interest legislation intended to fool the voters into thinking the measure is about something it is not.

In addition, according to California’s former Legislative Analyst – Prop. 46 will increase health care costs by $9.9 billion annually – approximately $1,000 per year for a family of four.

COMPLAINTS ABOUT ANTHEM AND BLUE SHIELD PROVIDER NETWORKSAre you still hearing complaints from patients about the confusion with Anthem and Blue Shield provider

networks? If so – make sure they call the Department of Managed Health Care (DMHC) for assistance and to register their complaints at 888-466-2219.

Due to prior consumer complaints, the DMHC is now conducting a non-routine audit. If they call your o�ce – make sure you or your sta� answer their questions.

PRAHALAD JAJODIA, MD

President’s Message

65457, Fresno, (7/14)Full Size: 8.5” x 11” Bleed: 8.75” x 11.25” Live: 7.5” x 10”Folds to: N/A Perf: N/AColors: 1c=(Black) Stock: N/A Postage: N/A Misc: N/AM

ERCE

R

A former employee sued me for wrongful termination.

For more information on these important benefits, and the special FMMS, KCMS and TCMS First-Time Buyers Program, please contact Mercer at:

800-842-3761

or email us at [email protected]

Sponsored by:

65457 (7/14) Copyright 2014 Mercer LLC. All rights reserved. • 777 S. Figueroa St., Los Angeles, CA 90017 www.CountyCMAMemberInsurance.com • [email protected]

Mercer Health & Benefits Insurance Services LLC • CA Ins. Lic. #0G39709 • 800-842-3761

You are not alone. Employment-related lawsuits are more common. What many physicians don’t realize is that help is literally a phone call away. FMMS, KCMS and TCMS members have access to a unique blend of risk management services and insurance specifically designed to assist physician groups in addressing these important employment issues. Among the features of the sponsored Employment Practices Liability program are:

A Helpline staffed by experienced employment defense attorneys. Any manager, officer or principal of your practice has access to the Helpline for obtaining advice on handling workplace issues, including internal sexual harassment complaints, discipline and employee terminations.

If a member seeks and follows Helpline advice on an employee termination or demotion which later results in a claim, there is a 50% reduction of the member’s EPLI deductible for that claim.

Free, comprehensive criminal background checks for newly hired and promoted managers/supervisors.

EEO compliance training for managers/supervisors. An internet-based training program, compliant with California law, provides supervisors with sexual harassment training.

Optional Wage and Hour Defense Coverage. (Subject to additional premium.)

Ask about our First-Time Buyers Program.




THIS IS A PERFECT EXAMPLE OF SPECIAL INTEREST LEGISLATION INTENDED TO FOOL THE VOTERS INTO THINKING THE MEASURE IS ABOUT SOMETHING IT IS NOT.


Fresno-Madera

FRESNO-MADERA MEDICAL SOCIETY 2014 PHYSICIAN COMMUNITY SERVICE AWARD

LIFETIME ACHIEVEMENT Dear FMMS member: RECOGNIZE A DESERVING COLLEAGUE! The Medical Society will bestow an award recognizing a physician who has gone beyond the call of duty in providing for the health and welfare of our community's residents during his or her lifetime. All nominees must be FMMS members. Criteria for this award includes:

• Extraordinary service and dedication to patients, the community or to the profession • Uncompensated services performed • High quality of care provided to patients

Previous award recipients: Drs. James Caffee, Roger Larson, Gilbert Roth, Robert West, Ronald Smith, Dwight Trowbridge, Lauren Grayson, Harold Hanson, John Murray, Max Millar, Ed Defoe, Thomas Eliason, Fred Cooley, Robert Peters, Jack Schiff, Burton James, Donald Knapp, Sathaporn Vathayanon, Jack Thorburn, Joseph Woo, Steven Parks, John Conrad, Bjorn Nelson, Theodore Steinberg, Malcolm Masten, John Bonner and Kenneth Jue. Nominations from the past three years will be considered. The recipient is selected by the FMMS Historical Committee and approved by the FMMS Board of Governors. The award will be presented at the Medical Society's November 8, 2014 dinner and installation gala. Please complete and return the form below by SEPTEMBER 8, 2014.

“We make a living by what we get, but we make a life by what we give.”

Winston Churchill

2014 PHYSICIAN “LIFETIME ACHIEVEMENT” AWARD

I nominate _____________________________________________________________________________ , MD (Please give specific and detailed examples for your nomination)

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Submitted by:____________________________________________________ Phone: ____________________ RETURN BY Mail to: Fresno-Madera Medical Society or Fax to: 224-0276 SEPT. 8 Historical Committee P.O. Box 28337 • Fresno CA 93729-8337


Fresno-Madera

FRESNO-MADERA MEDICAL SOCIETY 2014 PHYSICIAN COMMUNITY SERVICE AWARD

SPECIAL PROJECT OR SERVICE Dear FMMS member: RECOGNIZE A DESERVING COLLEAGUE! The Medical Society will bestow an award recognizing a physician who has gone beyond the call of duty to devote his or her time to a one-time or on-going special project or service either locally, statewide, nationally or internationally, that served(s) to promote the welfare and healthcare of the community or the medical profession. All nominees must be FMMS members. Previous award recipients are: Drs. Marc Lasher, Richard Whitten, Jr., Walter Byerly, Chun. C. Chan, David Pepper, Chun-Wai Chan, Lee Snyder, Women’s Imaging Specialists in Healthcare, Mohammad Arain, John Telles , Joan Voris and Alex Sherriffs. Nominations from the past three years will be considered. The recipient is selected by the FMMS Historical Committee and approved by the FMMS Board of Governors. The award will be presented at the Medical Society's November 8, 2014 dinner and installation gala. Please complete and return the form below by SEPTEMBER 8, 2014.

“It is well to give when asked, but it is better to give unasked, through understanding.”

Kahil Gibran

2014 PHYSICIAN “SPECIAL PROJECT OR SERVICE” AWARD I nominate _____________________________________________________________________________ , MD (Please give specific and detailed examples of your nominee’s project or service)

________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ ________________________________________________ Submitted by:____________________________________________________ Phone: ____________________ RETURN BY Mail to: Fresno-Madera Medical Society or Fax to: 224-0276 SEPT. 8 Historical Committee P.O. Box 28337 • Fresno CA 93729-8337


Fresno-Madera


PHYSICIANS:Looking for ways to:• Add more physical activity to your

lifestyle?• Be a role model and inspiration to

your patients and your community?• Spend more time with your family

and friends?

Consider volunteering ONE HOUR every month or two in the

Fresno-Madera Medical Society’s:WALK WITH A DOC Program

This walking program is risk free and requires no preparation. Physicians just need to:

SPEND A SATURDAY MORNING:• Presenting a 2-3-minute presenta-

tion on the health benefits of walk-ing from the perspective of your specialty

• Leading a 45-50 minute walk around Woodward Park in Fresno or Town & County Park in Madera

• Answering potential questions from the walkers

Encourage patients to take steps to improve their health

FRESNO: AUGUST 23 & SEPTEMBER 27

Woodward Regional Park Sunset View ShelterRegistration 7:15am

Walk Event 7:30am-8:30am

MADERA: AUGUST 2 & SEPTEMBER 7Town & Country Park

Pavilion AreaRegistration 7:15am

Walk Event 7:30am-8:30am

Ready to Volunteer? For a schedule of dates and times

Call the FMMS office: 559-224-4224x110 or send email to

[email protected]

Find us on Facebook:Fresno-Madera Medical Societywww.facebook.com/pages/Fresno-Madera-Medical Society/107731015917068

LUNCH & LEARNfor

Fresno-Madera Medical SocietyMembers’ Medical Staff

featuring

Update on Covered California: What Your Health Team

Needs to Knowpresented by

Fonda Winslow Provider Educator

California Medical Association Foundation

Thursday, August 14, 2014

12pm – 1pm

Fresno-Madera Medical Society offices

1040 E. Herndon Ave. #101

Discussion to include:

• Distinguishing and verifying eligibility

• Updated enrollment demographics

• Information on the “grace period” for subsidized Covered CA patients

• Overview of the ACA law

• Health plans’ Network adequacy

A light lunch will be available.No charge to attend, but due to space limitations,

no more than two (2) people per office may attend. Must RSVP by May 20 to:

Doreen Chaparro at [email protected] or 559-224-4224x 112.

network forum of the


2229 Q Street Bakers�eld, CA 93301-2900

661-325-9025 Fax 661-328-9372

website: www.kms.org

O�cers Alpha J. Anders, MD

PresidentMichelle S. Quiogue, MD

President-ElectEric J. Boren, MD

SecretaryBradford A. Anderson, MD

TreasurerWilbur Suesberry, MD

Past President

Board of Directors Alberto Acevedo, MD

Lawrence N. Cosner, Jr., MD Vipul R. Dev, MD

John L. Digges, MD Susan S. Hyun, MD

Kristopher L. Lyon, MD Ronald Morton, MD

Mark L. Nystrom, MD Edward W. Taylor, III, MD

CMA Delegates Jennifer Abraham, MD

Vipul Dev, MD John Digges, MD

Lawrence N. Cosner, Jr., MD

Sta� Sandi Palumbo

Executive DirectorKathy L. Hughes

Administrative Assistant

Editor’s Note: Due to a printing error in last month’s Vital Signs, this article was not printed. �is month the article is reprinted.

GUEST EDITORIAL

Medical Missionary Journey�omas R. Larwood, MD with Portia Choi, MD

�e following article is a remarkable human interest story of Dr. �omas Larwood’s life. It was �rst published in Levan Humanities Review, Volume 2, Issue 1 (2014). Over the next few months, we will continue with his story.

PART IWhy did I become a medical missionary? My background gives clues. My maternal Grandfather was a Methodist Minister in Iowa and my Mother was a church organist and choir director. It’s too far back to count, but my paternal great, great Grandparents were Presbyterian missionaries to the Nez Perce, a Native American tribe whose territory covered parts of Washington, Oregon, and Idaho. On the way, my great-great-Grandmother, Eliza Hart Spalding, along with Narcissa Whitman became the �rst two Caucasian women to cross the Rockies.

Many of our family’s activities were church related, as were most of my closest friends. We had several visiting missionaries stay at our home, which helped bring the world to us. �e road to becoming an Eagle Scout was a help. Of the many in�uences, the simplest answer was in Isaiah, Chapter 6 Verse 8: “Also I heard the voice of the Lord, saying, ‘Whom shall I send, and who will go for us?’ Then said I, ‘Here am I, send me.”

In the ninth grade I decided to become an aeronautical engineer but while a freshman at Fresno State, I became doubtful about spending the rest of my life with numbers, so I talked to my Dad about it. He, a civil engineer and later a teacher, was not given to telling me what to do but rather would ask questions to help me �nd my own answers. He asked me what I was most interested in. I thought a bit, and then replied, “Science and people.” �en he wondered what that might add up to. �e thought of my going into medicine had never seriously crossed my mind but it seemed to �t. �e idea stuck and I became a pre-med student, never to look back.

A�er two years in college, I was dra�ed in 1944 and spent two years in the Navy Hospital Corps, which made me a be�er doctor later. Near the time of my discharge from the Navy, I was due to give the sermon at my home church in Fresno for Youth Sunday. On my way from the Oakland Naval Hospital, I stopped by for a brief visit at the Methodist Youth Conference being held at Monte Toyon near Aptos. I was struck that evening by Dr. Day’s talk in which he asked, “Are you going to invest your life or just spend it?” That night I felt that I had been called, so declared to the Methodist Board of Missions, my desire to be a medical missionary. The decision was enhanced by Gordon Seagraves’s book, “Burma Surgeon,” more so when he visited our church. Also by Albert Schweitzer, an accomplished interpreter of Bach on the organ, who became a physician and spent the rest of his life in Africa, with amazing results.

Following my last year of pre-med at UC Berkeley, I attended the U.S.C. School of Medicine. You might say it was a trial run for the future when I went on a Methodist Youth Work Camp in Mexico the summer a�er the �rst year of med school. Wally Duncan, a pre-med student from Indiana, who spoke no Spanish, and I walked around the countryside with two Mexican nurses, who spoke no English, giving smallpox vaccinations. My Spanish sure improved! �e rest of the guys were building a new playing �eld and basketball court at the school, constructing all from local materials with men from the community. �e �esta that followed was participated in and enjoyed by all! My take-home message was that you do things with people, not for them.

Authors can be reached at [email protected] or [email protected].

PO Box 1029 Hanford, CA 93230

559-582-0310 Fax 559-582-3581

O�cers Je�rey W. Csiszar, MD

PresidentVacant

President-ElectMario Deguchi, MD

Secretary Treasurer�eresa P. Poindexter, MD

Past President

Board of Directors Bradley Beard, MD James E. Dean, MD

�omas S. Enloe, Jr., MD Ying-Chien Lee, MD Uriel Limjoco, MD

Michael MacLein, MD Kenny Mai, MD

CMA Delegate Ying-Chien Lee, MD

Sta� Marilyn Rush

Executive Secretary

Kern Kings


Tulare

3333 S. FairwayVisalia, CA 93277

559-627-2262Fax 559-734-0431

website: www.tcmsonline.org

O�cers �omas Gray, MD

PresidentMonica Manga, MD

President-ElectVirinder Bhardwaj, MD

Secretary/TreasurerSteve Cantrell, MD

Past President

Board of Directors Anil K. Patel, MD

Carlos Dominguez, MD Pradeep Kamboj, MD

Christopher Rodarte, MD Antonio Sanchez, MD

Raman Verma, MD

CMA Delegates �omas Daglish, MD

Roger Haley, MD John Hipskind, MD

CMA Alternate Delegates Robert Allen, MD James Foxe, MD Mark Tetz, MD

Sixth District CMA Trustee Ralph Kingsford, MD

Sta� Francine Hipskind Executive Director

�elma Yeary Executive Assistant

Dana Ramos Administrative Assistant

Editor’s Note: Due to a printing error in last month’s Vital Signs, this article was not printed. �is month the article is reprinted.

HIPAA and Your VendorsTim Torian, Torian Group, Inc., www.toriangroup.com

HIPA A’s updates have expanded the requirements of business associates. A “business associate” is a person or entity that performs certain functions or activities that involve the use or disclosure of protected health information on behalf of, or provides services to, a covered entity. If you have not already addressed this issue, you may need to create or update wri�en agreements with many of your vendors.

Business associate functions and activities include: claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; bene�t management; practice management; and re-pricing. Business associate services are: legal; actuarial; accounting; consulting; data aggregation; management; administrative; accreditation; and �nancial. �ese are non-employees that create, receive, maintain, or transmit protected health information (PHI). Examples of Business Associates include IT professionals, vendors such as so�ware companies, bookkeepers, accountants, trainers, consultants, and other contractors that have access to the practice’s PHI.

Business associates are responsible for their subcontractors, and they must comply with security and breach noti�cation rules. Healthcare providers are liable for the actions of BAs who are agents, but not for those that are independent contractors. Here are some steps to take to assure compliance and limit your exposure:

Implement or Update Security Policies and Procedures. A security breach poses the most signi�cant risk for employers and business associates. Most se�lements announced by HHS have involved a security breach. Six have resulted in se�lements exceeding $1 million. Employers and business associates should implement or update policies and procedures to ensure compliance with the HIPA A Security Rules. It must be in writing. Review the basics and update your documentation. Make sure you are conducting the required risk assessments and addressing the �ndings in a wri�en plan. Make sure your designated security o�cer is actually executing your security policies and plan. Consider outsourcing the IT portion of your assessment and corrective action if you don’t have the expertise.

Enter Into or Update Business Associate Agreements. For the �rst time, business associates are required to enter into business associate agreements with their subcontractors. �e business associate agreements may not require signi�cant changes for legal compliance purposes. However it is important to address potential liability for HIPA A violations. A signi�cant number of privacy and security breaches involve a vendor. Do you have the updated Business Associate Agreement on file? Have you verified that the agreement does not disclaim responsibility? Are you confident in your business associates? The Business Associate Agreement must identify if the associate subcontracts with other individuals or groups. For example, if the medical o�ce contracts with an IT professional and the IT professional subcontracts a computer technician and a breach occurs, who is responsible?

When writing or revising associate agreements, there are several critical elements to include:• Insurance – Ask if your business associates carries adequate liability insurance, and whether it covers a security

breach. • Security plan summary – A copy of the technical evaluation goes into the contract - requiring that the BA have

adequate security, and be able to provide a wri�en assurance of the security of protected data.• Incident response – How long does it take the BA to respond? How long does it take them to protect? How long

does it take them to remediate? Those types of questions all go into the contract. A 10 or 15 day time limit to disclose a security breach will give you time to do your own assessment and disclosure within the required 60 days.

In some cases you may need to educate those you contract with on these requirements. Covered health plans are not required to update their existing business associate agreements until September 22, 2014.

A sample Business Associate Agreement is provided by the Department of Health and Human Services: www.hhs.gov/ocr/privacy/hipaa/understanding/coveredentities/contractprov.html.

Update or Implement Privacy Policies and Procedures. Employers that have previously implemented HIPA A policies and procedures will need to update them to address regulatory changes. Changes in the last year include the new standard for determining whether a security breach has occurred and new procedures regarding requests for access to PHI in electronic form.

Conduct Training. Employees need to be informed of the changes to HIPA A regulations that are relevant to their job functions. At the same time, employers and business associates can take advantage of the opportunity to provide refresher training.

�e core of HIPA A compliance is good security practices. �e burden of documentation and good planning are worthwhile considering the alternative. For more information is available at www.toriangroup.com/compliance.

All material presented herein represents the views and information of the respective authors and is considered to be current and reliable. It does not necessarily carry the endorsement of the Tulare County Medical Society and/or its’ o�cers.


CLASSIFIEDS Members: 3 months/3 lines* free; thereafter $20 for 30 words.NON-Members: First month/3 lines* $50; Second month/3 lines* $40; Third month/3 lines* $30. *Three lines are approximately 40 to 45 characters per line. Additional words are $1 per word. Contact the Society’s Public Affairs Department, 559-224-4224, Ext. 118.

FRESNO

MEDICAL OFFICES

Gar McIndoe (661) 631-3808David Williams (661) 631-3816Jason Alexander (661) 631-3818

FOR LEASE8327 Brimhall – 1,629 rsf.

8327 Brimhall – 2,288 rsf.

Crown Pointe Phase II – 2,000-9,277 rsf.

3115 Latte Lane – 5,637 rsf.

3115 Latte Lane – 2,660-2,925 rsf.

1150-1160 Lerdo Hwy, Shafter1,766 to 3,793 sf.

9300 Stockdale Hwy. – 3,743 sf.

9330 Stockdale Hwy. – 5,754 rsf.

9900 Stockdale Hwy. – 2,085 sf.

500 Old River Rd. #185 – 3,071 sf.

SUB-LEASE4100 Truxtun Ave. –

Adm. & Billing – 6,613 rsf.

FOR SALE2019 21st Street – 2,856 sf.

3015 Calloway – 1,465-10,318 sf.

Crown Pointe Phase II – 2,000-9,277 rsf.

ANNOUNCEMENTS Fresno Gastroenterology welcomes board-certified physicians Dr. Paul Hanchett and Dr. Vivek Mittal. Referrals appreciated. Call 559-323-8200 or Fax: referral to 559-323-9200.University Psychiatry Clinic: A sliding fee scale clinic operated by the UCSF Fresno Dept. of Psychiatry at CRMC M-F 8am-5pm. Call 559-320-0580.

FOR LEASE Medical office. 1000sf, up to 2500 sf at NE corner First/Herndon & NW corner First/Bullard; starting at $1 psf++ by owner. Call 559-824-9966 or 559-930-4297.Office space at Chestnut/Herndon. Build to suit. 1200 sf. Call 559-287-3279.

. PHYSICIAN WANTED Spruce Multispecialty Group of Fresno, commit-ted to the private practice of medicine, is recruit-ing a BE/BC IM, Rheumatology or Pulmonary specialist. Contact Rathin at 559-289-9518 or [email protected].

Tulare


presents

Join us at the next Walk With A Docto take a step toward a healthier you!

All you need to do is lace-upa pair of comfortable shoes

and join us for some fresh air, fun and fitness.

TULAREDel Lago Park, Tulare, CA

Saturday, August 23, 20148:00am to 9:00am

VISALIARiverway Sports Park, Visalia, CA

Saturday, August 9, 20148:00am to 9:00am

Who can attend: ANYONE

For more information, please contactTulare County Medical Society at

(559) 627-2262

2015 Coding Book News It is that time again to start purchasing coding books. Order your 2015 editions of CPT, ICD-9, ICD-10, and HCPCS through us. We are o�ering extraordinary discounted rates and free shipping directly to your o�ce.

Please contact Dana Ramos, Provider Relations to order or obtain more information: 559-734-0393 or [email protected].

Tulare County Medical Society Upcoming EventsTRANSFORM YOUR FRONT DESK

�ursday, November 13, 20141:00 ro 4:00 p.m.Focus of training to be for front o�ce sta� on

the following:• Communication skills• Importance of collecting Co-pays• HIPA A compliance & confidentiality • Short-notice appointments

CHART AUDITING FOR PHYSICIAN SERVICES

�is class is a �ve-day class. November 14, 21, Dec. 5, 12, & 15, 20149:00 a.m. to 12:00 p.m

CERTIFIED MEDICAL CODER COURSE AND EXAM

�is class is a �ve-day class.November 14, 21, Dec. 5, 12, & 15, 20148:30 a.m. to 4:30 p.m. (one hour lunch break)

TCMS FAMILY DAYSunday, September 14, 2014McDermo� Field House

Details will follow by mail on all of the above events. If you have any questions, please feel free to call the Tulare County Medical Society o�ce at 559-734-0393 and ask to speak to Dana Ramos. You may also email her at [email protected] .

Medical OfficeSalary SurveyIf you would like to receive one to complete and participate in the con�dential results, email: [email protected] and she will submit a blank survey to you.

If you submit your complete survey by August 22, 2014 you can participate in a drawing for a $100 Vintage Press Gift Certificate.

If questions, please call our o�ce at 559-734-0393.

Our mission begins and ends with you, the policyholder. That means connecting our members to the highest quality products and services at the lowest responsible cost. Join us as we enter a new phase of our journey and advance with our vibrant new look and expanding o�erings.

hello.norcalmutual.com

Proud to be endorsed by the Fresno-Madera, Kern, Kings and Tulare County Medical Societies

N O R C A L M U T U A L I N S U R A N C E C O M P A N Y

VITAL SIGNSPost Office Box 28337Fresno, California 93729-8337

HAVE YOU MOVED?Please notify your medical society of your new address and phone number.

PRSRT STDU.S. Postage PAIDFresno, CAPermit No. 30

Documents

August 2014