The California Department of Health Care Services (DHCS) is expected next week to make its second round of retroactive interim payments to primary care physicians who have attested to their eligibility for the rate increases called for under the Affordable Care Act (ACA). These primary care payment increases have been put in place by the federal government in an effort to recruit more primary care physicians to treat low-income patients who will be newly eligible for health coverage in 2014. 

Although under the ACA the rate increases took effect on January 1, 2013, DHCS had been waiting for approval of its rate increase implementation plan from the Centers for Medicare and Medicaid Services (CMS). Approval was granted in late October, with the increases retroactive to January 1, 2013.

These payments are an estimate of what DHCS believed is owed to physicians for fee-for-service Medi-Cal claims retroactive to January 1. The payments will not, however, include claim level detail. The first monthly retroactive lump sum payment went out in early November, totaling more than $65 million.

DHCS has also begun making weekly lump sum payments, in addition to regular Medi-Cal payments, to primary care physicians enrolled in fee-for-service Medi-Cal who have attested. The weekly interim payments represent estimated increase amounts due until the DHCS computer systems can be updated to begin processing individual claims at the new rates, which could be as late as July 2014.

Each month going forward, DHCS will make retroactive fee-for-service Medi-Cal claims payments to physicians who newly attested the previous month. The next monthly lump sum payment is expected to go out next week. Weekly estimated payments for newly attesting physicians will begin the week immediately following the initial retroactive payment.

When DHCS updates its computer systems and begins paying claims at the new rates, it will issue a final settlement, which will reflect a “true up” of payment owed but not reimbursed, or possibly a refund request if overpaid. This final settlement will include claim level detail for the entire amount paid as part of this increase.

Attest today!

The increased payments are not automatic. To qualify for the increased payments, providers must first attest to their eligibility. The attestation form is available on the Medi-Cal website. Physicians are required to complete the attestation online (paper copies will not be accepted). (For more information on the specialists and subspecialists that qualify, click here or see the CMS Q&A.)

The increase also applies to services provided by physicians to Medi-Cal managed care patients. Medi-Cal managed care plans will receive funding for the increase in January of 2014. Plans will make the payments to their contracted primary care physicians shortly thereafter. One plan, Inland Empire Health Plan, released first quarter monies due to its physicians, even before it received the state's funding.

The California Medical Association (CMA) encourages practices to track all of the estimated lump sum payments received from DHCS, identified with RAD code 1801 (1801 A/R ACA interim payment). This upfront step should ease the reconciliation of those affected accounts once DHCS releases the claim level detail.

More information on the primary care rate increase can also be found in CMA’s Medi-Cal Primary Care Physician Rate Increase FAQs.

Where's my money?

While the vast majority of claims will be automatically reprocessed, DHCS has advised CMA that there are a few exceptions that will either result in a delay in receipt of the retroactive payments or may require the resubmission of claims. The exceptions include Medicaid crossovers; retroactive payments on Child Health and Disability Prevention claims submitted on the PM 160 form; and a small percentage of claims submitted with local codes where the crosswalk to a CPT code is not a one-to-one relationship. CMA is inquiring further with DHCS for more details.

It is also important that you have attested with a valid NPI in order to receive payment. You will not be notified if your attestation is unsuccessful because of an invalid NPI.

If you attested and have not received your expected fee-for-service payments yet, you can contact CMA for assistance at the number below.

Contact: CMA’s reimbursement helpline (888) 401-5911 or kmarck@cmadocs.org.