1. NEW ADDRESS FOR CLAIMS
The County of Orange has hired a new fiscal intermediary to process claims for the EMSF program. The new group, Advanced Medical Management, will replace American Insurance Administrators beginning July 1, 2006. All claims must be mailed to AMM at P.O. Box 3509, Long Beach, CA 90853. Claims sent to the previous intermediary will not be processed and will be returned by the U.S. Postal Service to the sender.

Other AMM contact information includes Customer Service: 800/206-6591; Appeals Fax: 562/766-2005; Administration Fax: 562/766-2006; and Claims Fax: 562/766-2007.

2. NEW STATE LAW
Changes in state law now disallow payment with state funds of claims denied by a third-party insurer if the patient has emergency room coverage under his policy [California Health and Safety Code Section 3; Section 1797.98c(c)]. Claims submitted through Section 1011 of the federal Medicare Prescription Drug, Improvement and Modernization Act of 2003 are exempt. This means that submission of claims through Section 1011 does not disqualify the claims from submission to the EMSF program. Claims may be billed to both programs.

As a result of this change, the EMSF program is only allowed to use Tobacco Settlement Revenue for the payment of third-party insurance denials. TSR funds only cover claims when the physician treated the patient within 24 hours of admission to the ER.

As previously required, third-party denials must be accompanied by a written statement of denial from the responsible third-party insurer. Absence of such documentation will invalidate the claim.

The EMSF program will now be able to reimburse eligible claims for patient care provided by a nurse practitioner or physician's assistant for care rendered under the direct supervision of a physician and on-site where the patient is being treated [Health and Safety Code Section 4; Section 1797.98e(1)]. To qualify for EMSF payment, eligible claims must be submitted by the supervising physician, and physician assistants and nurse practitioners must be enrolled in the program. Online enrollment is available on the AMM Web site at http://ochca.amm.cc/.

Physicians will now be required to wait four months and make two patient billing attempts before submitting a claim. This new policy assumes that the patient will be billed within 30 days of the date of service. However, if the first billing occurs later than 30 days from the date of service, the physician has to wait three months from that date before submitting a claim.

Physicians must continue to maintain appropriate records for a period of four years, including those that indicate the first date of patient billing, and must make those records available to EMSF auditors if requested.

3. TOBACCO SETTLEMENT REVENUE DECREASE
Tobacco companies have reduced their Tobacco Settlement Revenue payments by a substantial margin, claiming that their collective market share has dropped below the threshold outlined in the agreement with the states. The states that are a part of the agreement, including California, disagree with this action and have initiated litigation against the tobacco companies in an effort to restore the funds.

While this disagreement may take years to resolve, the direct impact on the EMSF program in FY 2006-07 is a loss of more than $600,000. In addition, in FY 2005-06, the program received a one-time infusion of approximately $450,000 in CHIP funds. As a result, in FY 2006-07, the program will see a reduction in funds of almost 11 percent. At the same time, the number of claims paid and received continues to increase by almost 10 percent a year.

Therefore, as of July 1, 2006, the EMSF reimbursement rate has been reduced from 90 percent of Medicare RBRVS to 83 percent of Medicare RBRVS. Please be advised that the rate may be adjusted at any time depending on available funding.

4. ELECTRONIC TRANSFER OF FUNDS AVAILABLE
EMSF providers are encouraged to sign up for direct deposit. Direct deposit ensures faster claims payment and saves administrative costs, which will result in more available funds for claims payment. To sign up, contact AMM at 800/206-6591.

Perry Cain is EMSF program administrator. He can be reached at 714/978-1160 or pcain@ocma.org.