August 07, 2017
Area(s) of Interest: Commercial Payors Payor Contracting Practice Management Payor Issues and Reimbursement
The California Medical Association (CMA) has learned that two health plans—Blue Shield and UnitedHealthcare (UHC)—have recently terminated their delegated agreements with Nivano Physicians Medical Group and are in the process of transferring patients from Nivano to alternative networks.
Nivano, also known as Northern California Physicians Medical Group with enrollees in Placer, Nevada, Sacramento, Yuba and Colusa counties, is currently on a corrective action plan with the Department of Managed Health Care (DMHC) for failure to meet financial solvency criteria. CMA has also received a surge of complaints about delays in authorizations and changes to Nivano policies and procedures over the past few months.
Blue Shield filed a block transfer request with DMHC on July 5 initiating the transfer of its 2,707 covered lives from Nivano. About 1,900 patients are being transferred into a new HMO Direct Contract Network with Blue Shield of California. A notice regarding this change was sent to Blue Shield participating physicians on July 21. The remaining 796 patients will be distributed to Hill Physicians Medical Group (728), Sutter Independent Physicians (34) and UC Davis Medical Group (34).
Blue Shield’s contract with Nivano will be terminated effective August 10, 2017, according to a recent notice sent to enrollees.
UHC is also terminating its relationship with Nivano and is reassigning most of its 1,750 covered lives effective August 1, 2017. UHC is transferring 756 patients to Hill Physicians and 771 to direct UHC HMO provider contracts to allow patients to remain with their former Nivano physicians. In the situation where a provider is not contracted with either Hill Physicians or UHC directly, patients will be allowed to complete treatment through continuity of care arrangements.
CMA is working closely with both Blue Shield and UnitedHealthcare to ensure claims that were authorized by Nivano, but performed after the termination dates, are still honored by the plans.
Practices that are experiencing problems with Nivano or issues resulting from the plan terminations are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or firstname.lastname@example.org.