July 31, 2015 – Facts v. Perceptions in JAMA’s ACA Study

 Dr. Joseph R. Maldonado
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July 31, 2015
Volume 15, Number 29

Dear Colleagues:

This week, the Journal of the American Medical Association published the findings of a survey which, among other goals, sought to ascertain the nature of changes in access to care, and the health of patients during the first two enrollment periods of the ACA. In addition, the survey wanted to identify differences for low-income individuals in states that expanded Medicaid versus those that did not.  The authors point out the importance of the survey findings for development of future health policy. Sadly, the survey merely serves to highlight the dangers in failing to follow fundamental evidence-based research principles.  If the results are used as intended by the authors, the astute clinician with good critical appraisal skills will understand how flawed research design leads to flawed health policies.

Flawed Core Design

The development of a clear and answerable question is at the core of study design.  Moreover, the findings must be relevant and applicable to the research subjects and/or to the beneficiaries of the study findings.  The study’s questions, methods and findings all fail the relevancy test. A critical appraiser should reject the conclusions of the authors, especially as they are unsuitable for policy development.  “Perceived” patient access to care does NOT equate to access to care.  The ACA may have given more Americans the ability to purchase health insurance. However, having an insurance card, especially a Medicaid product, does not translate to being able to find a doctor to treat you.

“Insurance card access” says nothing about actual access. Will a newly acquired Medicaid card be equal to, better or worse than the care they may have received without insurance or with a non-Medicaid insurance product?  Are these patients actually accessing doctors?  Does the patient’s perception of the quality of care meet the perceptions of other patients with non-Medicaid insurance products? Questions based on patient perception of these matters are important but they should not be the central drivers of health policy.

Evidence of Access Problems

Policy needs to be grounded in more scientifically valid observations— not patient bias.  However, if the goal is to pander to public perceptions to promote health policy that has other agendas as their drivers, then “perceived” improvements in healthcare or access will suffice.  There is growing evidence that access to care is a problem for patients who have signed onto ACA health insurance products.

We now have the data to study access to care based on claims.  Insurance carriers can certainly provide deep data on complication rates, readmissions, and other outcomes.  If we want to develop sound health policy while assessing the current outcomes of patient care under the ACA, let’s do so based on evidence extracted from well-designed studies that are truly relevant to meaningful health policy development.

Perception of care is not delivered medical care. Let’s begin the future with the facts.

JAMA study

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President

Please send your comments to comments@mssny.org


Please Take Just a Few Minutes to Complete our Health Insurance Hassles Survey
If you have not already, we urge you to take the opportunity to complete our latest health insurance hassles survey.  To complete the survey, click here.   It should take no more than just a few minutes.  Some of the initial findings of our survey include:

  • Many physicians see patient access to Out of Network coverage shrinking. 33% of the respondents indicated that they treat far fewer patients with out of network coverage than they did 3 years ago, and over 40% indicated that their patients’ OON insurance cover far less of a patients’ medical costs than it did 3 years ago
  • Health plan online participating provider lists are often inaccurate. 45% of the respondents indicated that they were erroneously listed as a participating provider on a health insurer’s website
  • Payments by Exchange plans are poor. Over 75% of the respondents indicated that Exchange plans paid them less than other commercial insurance products, with over 50% noting that the payments were “significantly lower” than payments for other plans offered by that insurer.
  • Health plans are shrinking their networks. Over ¼ of the respondents noted that there were not asked to participate in a new health insurance products offered by a plan with which they participated, with the overwhelming number of respondents noting that the reason was because the plan wanted to offer a “narrow network”.
  • Significant numbers of patients now have hefty deductibles. Nearly 20% of the respondents noted that patients with deductibles of $5,000 or greater comprised 10-25% of their practice, while 32% noted patients with deductibles between $2,500 and $5,000 comprised another 10-25% of their practice; and nearly 40% noted that patients with deductibles between $1,000 and $2,500 comprised another 10-25% of their practice.

These surveys help us to fully understand physician concerns with the contracting process between physicians and these health insurers. The findings also assist MSSNY’s advocacy efforts in the media and with policymakers to support fair contracting, comprehensive health insurer networks and comprehensive out of network coverage.

However, we need a representative cohort of physicians to respond to this survey is we are to be successful in advocating on yours and your patients’ behalf.  Please take just a few minutes to share your perspective.

United Healthcare and In-Network Labs
Effective September 1, 2015, UHC will require its network physicians and other qualified healthcare professionals in NYS to refer to or use network laboratories and pathologists for UHC Oxford NY members.  Any questions? Call United Healthcare Oxford network Laboratory Services Manager, Catherine Schaal at 631-584-0152.

55 Million Enrolled in Medicare; 3.3 Million in New York
55 million Americans are now covered by Medicare, according to a press release issued by CMS this week recognizing the 50th anniversary of Medicare and Medicaid.   The press release noted that there are over 3.3 million New Yorkers enrolled in Medicare, with over 2 million enrolled in traditional Medicare, and 1.25 million enrolled in Medicare Advantage plan.  Moreover, over 2.5 million New Yorkers have prescription drug coverage through Medicare, broken down between nearly 1.4 million enrolled in a Part D plan, and over 1.1 million enrolled in a Medicare Advantage plan with drug coverage. 

Over 2 million New Yorkers Enroll in Exchange; Nearly 75% is Medicaid
2.1 million New Yorkers enrolled in a health plan via the New York State Health Insurance Exchange, according to data released this week by the New York State of Health..  The data indicated that nearly ¾ of that 2.1 million, 1,568,345, were enrolled in Medicaid, with 159,716 enrolled in Child Health Plus, and 415,352 enrolled in commercial health insurance coverage.

The data also showed 9 health insurers enrolled 5% or more of total statewide commercial health insurance enrollees, led by Fidelis Care (20%), Health Republic (19%), Healthfirst (10%) and Empire Blue Cross Blue Shield (10%).  Of great concern, out of network coverage benefits were only available in 11 counties, with 21% of the enrollees in those counties selecting this coverage.   This lack of out of network coverage is exacerbated by the problem many consumers and physicians have reported regarding Exchange plans having inadequate physician networks to meet patient care needs.  Therefore, MSSNY continues to seek legislation (S.1846, Hannon/A.3734, Rosenthal) to require health insurers to offer out of network coverage in New York’s Exchange.

The overwhelming majority (58%) of those who received coverage in the Individual market were enrolled in Silver plans, while 18% enrolled in Bronze plans, 12% enrolled in Platinum plans, 10%  enrolled in Gold plans, and 2% enrolled in Catastrophic plans.  The State also reported that 55% percent of enrollees in the Individual market are in health plans with no annual deductible or deductibles of $600 or less.

While the overwhelming percentage of commercial health insurance coverage enrollment was in the individual market, the data indicated that 3,700 small businesses across New York State had procured coverage through the State Business Marketplace (SBM), providing coverage to nearly 15,000 employees and dependents.   Platinum plans were the most popular plan selected in the SBM representing over one-third of total enrollment. Gold and silver plans had enrollment at 27% and 26%, respectively, and only 13 % of SBM enrollees chose Bronze plans. 

Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline.

For other revisions, please refer to the New Program Changes (Supersedes all other document references) bullet on the website.

Legionnaires Disease Outbreak in South Bronx
NYCDOHMH is reporting an outbreak of Legionnaires’ disease in the South Bronx, resulting in two deaths. There have been 31 reported cases since July 10, compared with five confirmed cases during the same period in 2013 and 2014, combined. The rate of Legionnaires’ disease in the Bronx during 2015 has been 3.9 per 100,000 residents, more than twice the rate of the rest of the city. In High Bridge-Morrisania and Hunts Point-Mott Haven, the rate is 8.8 per 100,000. Dr. Jay Varma, New York City’s Department of Health and Mental Hygiene Deputy Commissioner for Disease Control, said what is “unique and important” about the recent outbreak is the “dramatic increase in one specific area.” Officials had noticed an initial uptick in cases last week followed by a large increase over the weekend.

Legislation Introduced in Congress to Address Burdensome Meaningful Use Requirements
This week U.S. Representative Renee Elmers (R-NC) introduced legislation (H.R. 3309, the Further Flexibility in HIT Reporting and Advancing Interoperability Act, or Flex-IT 2 Act) to reduce the overwhelming burdens physicians are facing with complying with federal EHR meaningful use requirements.   A press release by Rep. Ellmers noted that the bill would accomplish the following:

  • Delay Stage 3 Rulemaking until at least 2017, or MIPS final rules or at least 75 percent of doctors and hospitals are successful in meeting Stage 2 requirements.
  • Harmonize reporting requirements (MU, PQRS, IQR) to remove duplicative measurement and streamline requirements from CMS.
  • Institutes a 90-day reporting period for each year, regardless of stage or program experience
  • Encourages interoperability among EHR systems
  • Expands hardship exemptions, as they are very narrowly defined under current regulations

In the press release, Rep. Ellmers made the following statement:

Today’s legislation is key to supplying healthcare providers with flexibility and certainty, as they struggle yet again to meet the Centers for Medicare & Medicaid Services’ (CMS) stringent requirements pertaining to Meaningful Use. This legislation supplies relief by delaying Stage 3 rulemaking until at least 2017 in order to give providers time to breathe and a reprieve from the unfair penalties.”

“Only 19 percent of providers have met Stage 2 attestation requirements—a clear sign that physicians, hospitals and healthcare providers are challenged in meeting CMS’ onerous requirements. Given this basic fact, I’m uncertain why CMS would continue to push forward with a Stage 3 rule. From my conversations with doctors back home, it is clear they are eager for relief.”

“As a nurse, I can speak to the fact that a patients’ health and safety must be put first. This legislation will ensure that hospitals and providers can effectively share information so they can continue to focus their time and attention to caring for patients.”            

Transitioning to ICD-10-CM
This webinar will provide Part B providers with an overview of ICD-10-CM and will assist you with planning for the mandated ICD-10-CM transition. This session will include testing opportunities and transition stages that will help you prepare your office for the upcoming implementation. Please note: As per the CMS IOM Publication 100-09, Chapter 6, Section 30.1.1, National Government Services cannot make determinations about the proper use of codes for the provider. Questions related to ICD-9-CM and ICD-10-CM are handled by the American Hospital Association’s Coding Clinic. Details about this resource are available at http://www.ahacentraloffice.org.

Sessions are available on:

Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
Back in February 2015, it was brought to the attention of SME that NGS Medicare was seeking recovery action and offset for pulmonary function test done on the same day as an office visit.  In researching this matter, we found that CMS issued a MedLearn article, SE 1315.  This MLN article has no dates.

This old claims examiner (I) believed that the article is not appropriate for standard medical practice.  A Modifier 25 should not be needed to claim ANY diagnostic test (not a procedure) on the same day as a visit.  I asked CMS if they thought it necessary to use a Modifier 25 on the E&M code when an EKG or a lab test is also billed on the same day as a visit.  The author finds the position outlined in the article unnecessary. In addition, just because the RACs do not understand standard medical practice, is no reason for CMS to change the rule regarding a standard medical practice.

Therefore, I alerted CMS Central Office staff and asked that recovery actions for lack of a modifier 25 should be stopped and the article be rescinded.  As of today, July 28, 2015 we have been informed of the following:


SE1315 – Pulmonary Procedures and Evaluation & Management (E&M) Services

If any physician has been the subject of a recovery action on the basis of SE1315, the practice should file an appeal as soon as possible to get their money back if it was refunded or offset. 

Physician Groups Band Together to Address America’s Opioid Crisis
AMA convened task force engages physicians to curb opioid abuse

The AMA Task Force to Reduce Opioid Abuse announced the first of several national recommendations to address this growing epidemic.

The AMA Task Force to Reduce Opioid Abuse  is comprised of 27 physician organizations including the AMA, MSSNY, American Osteopathic Association, 17 specialty and six other state medical societies  as well as the American Dental Association that are committed to identifying the best practices to combat this public health crisis and move swiftly to implement those practices across the country.

“We have joined together as part of this special Task Force because we collectively believe that it is our responsibility to work together to provide a clear road map that will help bring an end to this public health epidemic,” said AMA Board Chair-Elect Patrice A. Harris, M.D., MA. “We are committed to working long-term on a multi-pronged, comprehensive public health approach to end opioid abuse in America.”

Medical Society of the State of New York President Joseph Maldonado, MD, said, “In an effort to reduce prescription diversion and abuse, New York has already taken the lead on this issue. New York’s physicians play a critical role in the effectiveness of the toughest opioid abuse program in the nation since August of 2013.  We are honored to become part of the AMA Task Force to address this epidemic.”

The AMA has long advocated in support of important initiatives aimed at addressing prescription drug abuse and diversion. This includes continued work with the administration and Congress toward developing balanced approaches to end prescription opioid misuse, as well as supporting congressional and state efforts to modernize and fully fund PDMPs.

The new initiative will seek to significantly enhance physicians’ education on safe, effective and evidence-based prescribing. This includes a new resource web page that houses vital information on PDMPs and their effectiveness for physician practices, as well as, a robust national marketing, social and communications campaign to significantly raise awareness of the steps that physicians can take to combat this epidemic and ensure they are aware of all options available to them for appropriate prescribing.

Diagnosing TBI in Your Office
Hospital data reveal that within New York State, over 550 persons per day sustain a brain injury caused by stroke, a Traumatic Brain Injury (TBI) or other factor(s). Actual incidence is higher as the prior numbers reflect only hospital based data; excluded are persons with brain injuries who seek treatment in a clinic, urgent care, or physician’s office, and those with the injury who are not aware of it.  Even a “mild” brain injury can result in lifelong disability, especially if proper treatment is not received.

To promote recognition and treatment of brain injury, the State University of New York at Albany’s School of Public Health produced a webcast, “Recognizing and Treating Mild Brain Injury” for health practitioners, in collaboration with a Federal grant awarded to the New York State Department of Health. The webcast, via “Public Health Live” received rave reviews from the physician, nurse, and nurse practitioner audience.  The program features the one page, evidenced based TBI diagnostic tool, “Acute Concussion Evaluation” (ACE) available free of charge from the Centers for Disease Control and Injury Prevention (CDC) website.

The goal of the program is to increase the number of practitioners able to recognize even the subtle signs of brain injury which may not surface until weeks even months after the initial trauma. That diagnostic ability can save lives and ameliorate the suffering caused by brain injury. The program is easy to access, and lists brain injury related information and materials, including the link to the ACE, all available free of charge. Continuing Medical Education Credits are available as listed below. Practitioners are encouraged to log on to the training at: http://www.albany.edu/sph/cphce/phl_0415.shtml

Continuing Medical Education Contact Hours: The School of Public Health, University at Albany is accredited by the Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. The School of Public Health, University at Albany designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits TM. Physicians should claim credit commensurate with the extent of their participation in the activity. Continuing education credits will be available until February 2016.

The training was paid in part by a grant from the Health and Human Resources and Services Administration to the NYS Department of Health Grant # H21MC26921.  For more information about the TBI Grant contact, helen.hines@health.ny.gov.


Doctors Digital Agency
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July 24, 2014 – All in the Family??

 Dr. Joseph R. Maldonado
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July 24, 2015
Volume 15, Number 28

Dear Colleagues:

Editor’s note: MSSNY President Dr. Maldonado is on vacation. This week’s Enews introduction is written by Michelle A. Leppert, CPC, a senior managing editor for JustCoding.com. And an editor for HCPro publication, Briefings on Coding Compliance Strategies.

Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very confusing trying to figure out who was in the family and who wasn’t.

CMS created the same kind of confusion last week when it basically cut a deal with the American Medical Association (AMA). The AMA, you may recall, has been very vocally opposed to ICD-10 being implemented in any way, shape, or form. To get AMA to cease and desist its defiance, CMS gave AMA something it wanted: no penalties for some coding errors and advanced payments if the technology goes kerflooey.

I can totally understand advancing payments if the system doesn’t work. That’s pretty straightforward. The physician gets paid on time and doesn’t have to worry about going under because of something he or she can’t control. The physicians will have to repay the advanced payment once the system is running smoothly, so they aren’t getting extra money. They just get a hedge against a Y2K meltdown. 

Coding from the Right Family?

The confusing part of the pact is the hold harmless for miscoding. AMA initially wanted physicians to get a pass on coding errors for two years. I’m pretty sure AMA knew that wasn’t going to fly, but when you negotiate, you always start high. In the final deal, CMS stated auditors will not deny a claim “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

CMS does not, however, define a family of codes. Is it a category of codes, such as S00, superficial injury of head? That could be interesting. S00 has nine subcategories of codes, each with their own subcategories. Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.

Maybe CMS considers a family to be the smallest group of subcategories. So under S00, we could go all the way down to S00.46-, insect bite (nonvenomous) of ear as a family. That would give us three codes in the family:

  • 461, insect bite (nonvenomous) of right ear
  • 462, insect bite (nonvenomous) of left ear
  • 469, insect bite (nonvenomous) of unspecified ear

That seems reasonable. The only missing information is the laterality. Not a huge deal, but really the physician should be documenting it. Maybe the coder just couldn’t find it or was in a hurry and defaulted to unspecified.

Let’s consider open wounds of the eyelid and periocular area (S01.1). This is a subcategory under open wound of the head (S01). We’ve already narrowed it down to a specific area. The question becomes, is everything under S01.1- a family? I hope not. Here’s why. The first subcategory under S01.1- is S01.10- (unspecified open wound of eyelid and periocular area). S01.10- further specifies laterality:

  • 101-, unspecified open wound of right eyelid and periocular area
  • 102-, unspecified open wound of left eyelid and periocular area
  • 109-, unspecified open wound of unspecified eyelid and periocular area

That last one’s a killer because it tells you nothing. No wound type, no laterality.

Subsequent Encounters

Additional subcategories under S01.1- specify the type of wound:

  • Laceration with (S01.12-) and without foreign body (S01.111)
  • Puncture wound with (S01.14-) and without (S01.131) foreign body
  • Open bite (S01.15)

I can see not penalizing someone for failing to reporting the “without foreign body” code instead of requiring coders to query if the physician doesn’t document that no foreign body remained in the wound. The question of with or without foreign body becomes tricky when you start looking at subsequent encounters.

If S01.1- is a family, claims won’t be denied if you report S01.109- instead of S01.132- (puncture wound without foreign body of left eyelid and periocular area). Fractures will be even more confusing, largely because ICD-10 includes so many variations of fracture codes. What about specificity for diseases, such as diabetes? Where do you draw the family line? Is it the type of diabetes? So all codes under E11 (Type 2 diabetes mellitus) are one family?

Or do you go to the first subcategory and say all codes under E11.3- (Type 2 diabetes mellitus with ophthalmic complications) are the same family and therefore we won’t deny the claim if you have any E11.3- code. Maybe CMS goes one step further and really narrows down the family to E11.31- (Type 2 diabetes mellitus with unspecified diabetic retinopathy), which includes two codes:

  • 311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
  • 319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macularedema

We don’t know. I’m not convinced CMS knows at this point.

Something else we don’t know—how does this deal with AMA affect hospitals? CMS and AMA both only reference Part B physician fee schedule claims. What about Part A claims? Is CMS going to extend the same breaks to hospitals? Again, we don’t know.

CMS may have finally gotten the AMA on board with ICD-10, but it sure created a lot of additional confusion along the way.

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President
Please send your comments to comments@mssny.org


Reminder: MSSNY General Counsel Develops Template Forms for Physicians To Comply With Out of Network Law Required Disclosures
As a reminder, MSSNY’s General Counsel Donald Moy, Esq. has developed model template disclosure forms that physicians can use in their practices to comply with the new “surprise medical bill” law which took effect on April 1, available from the MSSNY website (Members Only) here. These new requirements include:

                             Network and Hospital Affiliations

All physicians must provide to patients or prospective patients in writing or on the physicians’ website prior to the provision of non-emergency services:

  • The health care plans with which the provider participates; and
  • The hospitals with which the health care professional is affiliated

For the model form physicians can use in their practice, click here.

Model Form #1

In addition, this participation/affiliation information must be provided verbally at the time an appointment is scheduled.

                                               Fee Disclosure

Physicians who do not participate in the network of a patient’s or prospective patient’s health care plan must:

  • Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request;
  • Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided

For the model forms physicians can use in their practice, click here, Model Forms #2-A, 2-B and 3

Other Health Care Providers Involved in Providing Patient Care

Allphysicians who refer or coordinate services for patients with another provider must provide to their patients the name, practice name, mailing address, and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology; radiology; or assistant surgeon services, in connection with care to be provided

  • in the physician’s office;
  • as coordinated by the physician; or
  • as referred by the physician.

For the model forms physicians can use in their practice, click here, Model Form, #4

Other Physicians Involved in Hospital Care

At the time of a patient’s pre-admission testing, registration or admission for scheduled hospital admission or outpatient hospital services, all physicians must provide their patients with the name, practice name, mailing address and telephone number of any other physician whose services will be arranged by the physician and are scheduled at the time non-emergency services are scheduled.

For the model forms physicians can use in their practice, click here, Model Form #5.

There are also numerous other provisions incorporated into this new law which took effect this past April 1.  For a summary click here.

Residents Salary & Debt Report 2015: Are Residents Happy?
Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program. In 2015, the average resident salary—$55,400—was a slight increase over that reported in Medscape’s 2014 Residents Salary & Debt Report ($55,300). The figure averages higher earnings in such specialties as critical care and oncology and lower earnings in other specialties, such as primary care. Some 68% of residents have a considerable amount of medical school debt (exclusive of any other debt): $50,000 or more. Well over one third (37%) of residents have over $200,000 in debt, and over one fifth (22%) have $100,000-$200,000. Another 9% have $50,000-$99,999, and 10% have less than $50,000. A fortunate 22% of residents have no debt.

Nearly two thirds (62%) of the residents we surveyed reported that they considered their compensation fair. This is higher than what was reported by practicing physicians; almost one half (47%) of primary care physicians feel fairly compensated, and 50% of specialists feel fairly compensated. Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program.

Missed the Meaningful Use Town Hall Meeting? Watch a Re-Broadcast
This week the AMA hosted a special national “town hall” meeting in Atlanta to highlight physician concerns with electronic health record systems (EHRs).  The forum gave physicians an opportunity, both in person and via Twitter, to express concerns with their efforts, often futile, to achieve meaningful use of EHR systems in order to avoid Medicare payment penalties.  In many cases, physician speakers noted that they had been “early adopters of EHR technology, yet still could not achieve meaningful use Stage 2, and had simply chosen to accept penalties in lieu of the interference they were facing in trying to provide needed patient care.  Moreover, physicians shared frustrations about the failure of EHR companies to assure that medical record systems become interoperable to better enable the sharing of treatment information when physicians treat the same patient.  To watch a re-broadcast of the “Town Hall” event, click here: http://live.breaktheredtape.org/.  To read more about this event, click here.

Your New Video – Countdown to ICD-10: 10 Facts about ICD-10
The Centers for Medicare & Medicaid Services (CMS) has released an exciting new video to help ease your transition as we count down to ICD-10 implementation. This animated video highlights ten facts of what to expect during the ICD-10 transition.

The following videos are currently available for viewing on CMS’s YouTube channel:

The 10/1/2015 implementation date is fast approaching and these videos will provide an overview of ICD-10 as well as explain the benefits of the new code set. It will also provide implementation guidance and coding examples. We hope you find these videos to be a valuable asset as we count down to ICD-10.

National Government Services Needs YOUR Help! Take Their Survey!
We know how busy you are but we urgently need our customers’ perspective. We are counting on you and your staff to complete the Medicare Satisfaction Indicator (MSI) and website ForeSee surveys. It takes time, but the benefit of taking these two surveys will help you as a Medicare Provider and us as a Medicare Contractor determine how we are performing.  Are you happy with us?  We hope you are, but if not, we need to know that too!  Good, bad, or indifferent, your feedback is a necessity!

Both surveys are available on their website at www.NGSMedicare.com.  The MSI survey banner is displayed on the home page.  For the website ForeSee survey, you are randomly chosen to take it, so whenever you do get that option, please click “yes, I’ll give feedback.”  As we work with your suggestions, you will be glad you took the 5-10 minutes to complete the survey.

This link will take you to the MSI survey for Part A and Part B providers.

Link to CMS MAC MSI Survey

What You Should Know about MEDICARE/MEDICAID Dual Eligibles
The following is provided as an informational reminder from Socio-Med VP Regina McNally:

As you should know, effective July 1, 2015 NYS Medicaid is no longer paying the 20% of the 20% coinsurance from the Medicare claim for Medicare/Medicaid dual eligible patients.  The NYS budget did not include funding to maintain this benefit from the NYS Medicaid Program. The final budget, accepts in part, the Executive’s proposal to limit Medicaid payments for dual eligibles’ Medicare Part B coinsurance amounts so that the total Medicare/Medicaid payment to the provider does not exceed the amount that the provider would have received for a Medicaid-only patient. The final budget accepts this cut with respect to dual eligibles in fee-for-service Medicare, but rejects it for dual eligible beneficiaries who are enrolled in Medicare Advantage plans. This cut took effect on July 1, 2015.

The June 2015 Medicaid Update on this matter reads as follows:

Effective July 1, 2015 a change to New York State Social Services Law adjusts Medicare Part B coinsurances reimbursement methodology for practitioner claims: Medicaid presently pays practitioners the full Medicare Part B annual deductible and partial Medicare Part B coinsurance amounts (20 percent of the Part B coinsurance) for Medicaid covered services provided to Medicare/Medicaid dually eligible recipients. Pursuant to recent changes to Social Services Law, New York State Medicaid has revised the reimbursement methodology for practitioner claims effective July 1, 2015. 

Beginning July 1, 2015, Medicaid is no longer reimbursing partial Medicare Part B coinsurance amounts. The total Medicare/Medicaid payment to the provider will not exceed the amount that the provider would have received for a Medicaid-only patient. If the Medicare payment is greater than the Medicaid fee, no additional payment will be made.

Note: The Medicare and Medicaid payment (if any) must be accepted as payment in full. Per State regulation 18 NYCRR Section 360- 7.7, a provider of a Medicare Part B benefit cannot seek to recover any Medicare Part B deductible or coinsurance amounts from Medicare/Medicaid Dually Eligible Individuals.

There is no change to the current reimbursement methodology of Medicare Part B coinsurance for the following: Ambulance providers; Psychologists; Article 16 clinics; Article 31 clinics; and Article 32 clinics. Medicaid will continue to reimburse these providers the full Medicare Part B coinsurance.

Reminder: If a patient is dually eligible, private practitioners must bill Medicare prior to billing Medicaid for the Part B co-insurance. Most claims are submitted to Medicare and are automatically crossed over to Medicaid for processing.

If a medical practice is enrolled with a Medicare Managed Care (MMC) (Medicare Part C), when the MMC pays the practice the payment is expected to be considered as payment in full.  The medical practice should review its MMC contract.

Regrettably, this goes back to the federal Balanced Budget Act of 1997.  The BBA included a clause that stated the states no longer had to pay the coinsurance amounts for “dual eligible.”  The BBA was passed at the time when MSSNY had just won the Medicare/Medicare Crossover lawsuit.  Therefore, NYS had decided to continue paying a small portion of the Medicare Coinsurance amount.  However, it just so happens that this year, the state decided to no longer include payment for this in the state budget.  The state will still cover the Medicare Part B deductible, though.

The statute  §1902(n)(3) of the Social Security Act) says that, where the State Medicaid program limits the amount it will pay for deductibles and coinsurance for QMBs, “for the purposes of applying any limitation under title XVIII [Medicare] on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under title XVIII [Medicare] plus the amount of payment (if any) under the State plan [Medicaid] shall be considered to be payment in full for the service…”

Therefore, under Medicare rules, the provider has been paid in full if it receives the normal Medicare payment amount for the service plus any amount that Medicaid pays, even if Medicaid pays nothing.  It doesn’t matter that the provider is not enrolled in Medicaid, billing beyond what Medicare and Medicaid pays would be a violation of Medicare rules.

When treating a dual eligible, there is mandatory assignment for the Medicare claim.  This is not a new rule.

Can a physician who is not enrolled in Medicaid bill a Medicaid recipient for the Medicare deductible?

The answer is no. Under no circumstance can a provider balance bill dual eligible.  The provider needs to enroll in the Medicaid program as a non-participating provider for Medicaid to cover the Medicare deductible. Being enrolled in Medicare, you need to be cautious about not treating dual eligibles in your medical practice. Any patient should not be discriminated against because of the health insurance they have or don’t have.

Since a medical practice should not discriminate against any patient based on the type of payer/insurance/plan by which the patient is covered, a practice can make a business decision to limit the amount of patients it can handle from a particular plan.  So, the practice can say it can’t take any more patients from “X” plan.

Questions Regarding Out of Network Telephone Audits

Question: I am an out of network physician, but a health plan wants to audit me. What are my obligations?

Being out of network, physicians would be non-participating and therefore have NO contract with a health plan. To par or not to par with a health plan must be an individual business decision by any physician/practice.

A physician without a contract with a health plan who is asked to go through an audit process, should tell the health plan that a patient authorization is required before an audit can be conducted.  Without a contract, physicians have no obligation to a health plan but do have a privacy obligation to their patient. If the patient is covered by a health plan, the link is between the health plan and the patient. If the health plan wants the patient’s medical record, the health plan needs to obtain the patient’s authorization for disclosure of his/her medical information by the physician.

Physicians without contract with a health plan have no obligation to the plan.  The physician’s only obligation is to the patient.  Physicians should not leave themselves open to violations of their patients’ privacy.  Without the patient’s authorization to disclose their medical record, the physician has no authority to disclose the information.

Question: What if I have a contract with the plan?

If the health plan takes a negative position and wants the call to proceed without the benefit of recording and the physician has a contract, then the physician would need to make a business decision about the possibility of putting his/her contract at risk of termination.

Question: I am out of network. What if I receive a check from the plan?

When a physician has no contract with a health plan and the health plan inadvertently sends the physician a check, if the physician cashes the check, there could be an implied assignment of benefit whereby the physician is expected to “stand in the shoes of the patient.” If the physician does not want an implied assignment of benefits, the word “VOID” should be written across the face of the check and the check should be returned to the health plan with the instruction to reissue the check to the health plan’s insured/patient.

Question: Can I record a telephone audit?

It would be a good idea and a professional courtesy to inform the auditor that the telephone call will be recorded.  If the health plan representative chooses not to be recorded, then the audit would not need to proceed for a physician who has no contract. 

In reference to recording a telephone audit, the law on this is as follows:

NYS Penal § 250.00 Eavesdropping; definitions of terms.

    The following definitions are applicable to this article:

  1. “Wiretapping” means…   
  2. “Mechanical overhearing of a conversation” means the intentional overhearing or recording of a conversation or discussion, without the consent of at least one party thereto, by a person not present  there at, by means of any instrument, device or equipment…..

                                                                                   –From Regina McNally

Comprehensive Care for Joint Replacement (CCJR) Model Webinar Materials Posted
In follow-up to the July 9, 2015 announcement of the Comprehensive Care for Joint Replacement (CCJR) Model, the CMS Innovation Center hosted two webinars on July 15 and July 16, 2015. These webinars focused on providing an overview of the Model and provided an opportunity for attendees to ask questions.

The materials from these overview webinars are now available on the CCJR Overview webinar page. To access the audio recordings of both webinars, an email address is required. If already registered, please use the same email address used at the time of registration. Additional information on the CCJR Model can be accessed through the CCJR Model web page 

Calling All Amateur Photogs for MSSNY’s Social Media Feeds
We’d like to include more happenings from around the state in our Twitter, Facebook and Instagram feeds. If you’re at an event that you think might be of interest to our followers, please snap a picture with your phone and send to jvecchione@mssny.org with your name.  Be sure to include a caption or some identifying words. If you’re traveling around our beautiful state this summer, send us a photo!


Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.


eNews July 17, 2015 – Physicians and “Freebies”

 Dr. Joseph R. Maldonado
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July 17, 2015
Volume 15, Number 27

Dear Colleagues:

This past week, Joe Queenan wrote a column in the Wall Street Journal entitled “Is There a Doctor in the House?”  Mr. Queenan suggests that physicians ought to behave like many other business owners who throw a patient/customer/client a “freebie” once in a while.  He proposes that procedures that an individual undergoes on a regular basis should form the basis for the occasional freebie.  Mr. Queenan initially rejects the notion that major surgical procedures, imaging studies and other infrequent procedures should not be the subject of the freebie but then gives as freebie examples—  nasal endoscopies, acupuncture and physical therapy.  Mr. Queenan’s column is perhaps part tongue-in-cheek humor, but it reflects quite accurately the ignorance of many Americans regarding how much free work physicians do. Perhaps the ignorance is predicated on how he has constructed his view of what constitutes a “freebie.”  This is suggested by a question he raises—“But when you see a physician several times a year, shouldn’t you feel entitled to a freebie every once in a while?”

Americans, both rich and poor, have developed a sense of entitlement.  Programs such as Medicare, Medicaid and now, the ACA, have promoted a sense of entitlement for many Americans regarding healthcare.  They are not just entitled to care.  They are entitled to FREE care.  What Mr. Queenan fails to recognize is that we DO provide free care.  We do so, consciously and unconsciously. After going the extra mile, we often fail to bill for a service.  We merely decided that providing the service was “doing the right thing” and we fail to bill the patient.  Sometimes we are aware of the personal cost to a patient for a co-pay or deductible and we simply fail to bill the service altogether for fear that forgiving the co-pay or deductible will lead to criminal and professional charges.

In my experience, doctors never brag or advertise that they’ve done a good deed.   They just do their mitzvahs— no need to announce it.  In doing so, they risk engendering ingratitude from folks with a sense of entitlement who then expect freebies at every visit rather than every fourth visit.  Most of the time, these “entitled” folks are unaware of the charity work or medical missions their doctors have taken in lieu of a vacation – at personal cost of family time, resources and compensation.

Should we highlight more of our own freebies to our “entitled” patients?  I don’t think so.  We didn’t give the freebie to garner their loyalty or adulation.  We gave them for altruistic reasons, knowing many would not appreciate them but feel they “earned” those freebies.  In fact, I would suggest that some may feel that they are doing us a favor by coming to us and allowing us to bill for the other services which should have been freebies, too.  When Mr. Queenan realized his dry cleaner never threw him a bone, he stopped taking his business to that cleaner, even though, in his own words, “they were consummate professionals.”  Most of us would still remain available to ungrateful and entitled patients.  Others, having provided innumerable silent freebies to countless patients would be happy to simply say to those who feel entitled to another freebie and opt to leave us for greener pastures elsewhere—   “Don’t let the door hit your backside on the way out.”

Mr. Queenan, may I open the door for you as you leave?

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President
Please send your comments to comments@mssny.org



NYSIF Announces Launch of Online Medical Provider Portal
The New York State Insurance Fund recently announced the launch of its new online Medical Provider Portal at www.nysif.com. The new portal will allow registered providers and third party billers to retrieve claims payment information regarding their workers’ compensation patients.

Once a provider registers at nysif.com, he or she will be able to self-serve and obtain access to an explanation of benefits (EOB), bill payment status (with amount paid), claims covered on an issued check and claim-by-claim pricing and payment accounting.

To register for a medical provider user account, go to www.nysif.com and follow the instructions for registration. Providers will need a copy of their latest check from NYSIF to complete registration.  To safeguard the privileged information of both the medical provider and the claimant, obtaining EOB and bill payment information will now require a log-on before accessing that data.

If a provider uses a third-party billing company, the biller must also register for an account to obtain access to the provider’s information.  Once the vendor completes the registration, NYSIF will send the vendor a unique identifier code that they must share with the provider. Once a medical provider has designated the vendor as an approved third party biller, the biller will have online access to that provider’s medical bill payment information and explanation of benefits. Please note only the medical provider can approve access to the portal for the third party billing company.

Please take a moment to visit nysif.com today and register! 

Fed Up with EHRs? Share Concerns during AMA Town Hall Meeting
This Monday night, July 20, from 7 to 8:30 p.m., the AMA, in conjunction with the Medical Association of Georgia, will be hosting a special town hall meeting in Atlanta to discuss concerns with electronic health record systems (EHRs). The event will be live-streamed so physicians can participate at home and via Twitter with #FixEHR.

Among the national and local leaders who will be a part of the conversation will be Rep. Tom Price, MD, a Republican from Georgia’s 6th District, and AMA President Steven J. Stack, MD.

According to the AMA, physician participation in Stage 2 of meaningful use is less than 10 percent, even though 80 percent of physicians have adopted EHRs. Moving forward with Stage 3 could mean less time with patients, hindrances to practice innovation and costly penalties. Many physicians have complained that government requirements have affected EHR technology so it does not productively synch with physician workflow, such as interfering with face-to-face discussions with patients, requiring physicians to spend too much time performing clerical work and creating new costs that divert resources away from patient care improvements. Meanwhile, the much anticipated benefits of being able to share important patient health care information electronically among providers in different settings have gone unfulfilled.

CCNY Medical School to Welcome First Class in 2016
The City College of New York announced the establishment of the CUNY School of Medicine at City College in partnership with Bronx-based St. Barnabas Hospital, which is part of the SBH Health System. The new Harlem-based medical school, whose first class is scheduled to begin fall 2016, will be an expansion of City College’s Sophie Davis School of Biomedical Education. Established in 1973 on the City College campus, the Sophie Davis School currently offers a unique seven-year BS/MD program that integrates an undergraduate education with the first two years of medical school.

The new medical school on the City College campus builds on the strong record of achievement of the Sophie Davis School of Biomedical Education, whose mission is recruiting underrepresented minorities into medicine, increasing medical care in historically underserved communities and boosting the number of primary care physicians.

City College President Lisa S. Coico said the newly established school would nurture young students to embrace a career focused on caring for their fellow citizens with passion, empathy and respect. “The need for more physicians in many communities in our city, particularly in the communities surrounding City College, remains dire,” she said. “By establishing this resource, City College is both helping to address this critical need and fulfilling a vital community service.” 

CMS Releases Proposed Medicare Payment Rule for 2016
CMS recently released its proposed Medicare Part B payment rule for 2016.  To read the CMS press release highlighting some of most notable aspects of the proposal, click here.  The proposal begins to implement aspects of the Merit-Based Incentive Payment System (MIPS) enacted as part of the SGR repeal legislation as well as making changes to several of the quality reporting initiatives that will in 2019 be consolidated into the MIPS program, including the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (Value Modifier), and the Meaningful Use Program.   The SGR repeal proposal also provided for a 0.5% increase in the conversion factor July 1, as well as another 0.5% increase on January 1, 2016.

Among the issues items brought up in the proposal:

  • Establish Medicare fees for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. (as referenced in last week’s MSSNY’s e-news);
  • Bringing up to 300 the number of measure reportable under the PQRS program. If an individual practitioner or group practice does not satisfactorily on PQRS quality measures, a 2% negative payment adjustment would apply in 2018;
  • Proposing a methodology to impose a 0.25% reduction in Medicare spending due to reductions in certain misvalued codes, as required by provisions incorporated in prior year’s legislation (the “ABLE” Act enacted in 2014).  CMS noted that it could make further misvalued code changes in the final rule to move closer to the statutory goal of 1% based on public comment.
  • With regard to 2018 Value-Based Modifier payments (which will be based upon 2016 performance), to set the maximum upward adjustment of +4.0 times the adjustment factor (to be determined after the conclusion of the performance period), for groups with ten or more EPs; +2.0 times the adjustment factor, for groups with less than 10 EPs;  as well as to set the potential penalty in 2018 to -4% for groups with ten or more EPs, and -2% for groups with less than 10 EPs.
  • Updating self-referral limitation provisions to establish a new exception to permit payment to physicians for the purpose of employing non-physician practitioners.

MSSNY will be working with the AMA and the federation of medicine to review the rule and to make comments on key components.  Here is a link to the entire 2016 proposed Medicare payment rule.

Telemedicine Companies Popping Up in New York
Pager — a New York-based service that’s looking to revive the practice of house calls by doctors — just raised $14 million in a funding round co-led by Aston Kutcher’s firm Sound Ventures, valuing the company at around $75 million. “Telemedicine” services, in which doctors diagnose and treat patients on the phone and online, have been multiplying lately—like Doctor On Demand, Teladoc, MDLive and HealthTap.

But Pager has spent the past year building a network of physicians and nurses in New York City who, in addition to telemedicine services, can visit your home to treat everything from minor injuries to the flu.

Rates are $25 for telemedicine and $50 for an initial doctor’s visit. Subsequent visits are $200 and reimbursable as out-of-network by some plans. Pager expects to be in-network with several major insurers later this year.  

CMS Proposes Part A/Part B Medicare Bundle for Lower Joint Replacement
CMS has proposed to implement a new Medicare Part A and B virtual bundled payment model –  the “Comprehensive Care for Joint Replacement (CCJR)” model – under which acute care hospitals in certain selected geographic areas will receive retrospective reward payments or face financial liability relating to episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity.   The initiative is designed to test “whether bundled payments to acute care hospitals for LEJR episodes of care will reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.”

Under the proposal, the program would be implemented in 75 MSAs across the country, including the New York City and Buffalo areas.  There would be a 5 year performance period, beginning January 1, 2016, and ending December 31, 2020.

Under the model, an episode of care would begin upon admission to a hospital for an LEJR procedure and would end 90 days after the date of discharge.  The episode would include the LEJR procedure, inpatient stay, and all related care covered under Medicare Parts A and B within the 90 days after discharge, including hospital care, post-acute care, and physician services.  While spending under Part A and Part B would continue to be made on a fee for service basis, the acute care hospital that is the site of surgery would be held accountable for spending during the episode of care.  Depending on the hospital’s quality and cost performance during the episode, the hospital would either earn a financial reward or be required to repay Medicare for a portion of the costs.  Penalties would not be imposed the first year of the program, and be phased in beginning Year 2.

According to a CMS webinar describing this proposal this week, only the acute care hospitals where the surgery is performed would be ultimately liable for making repayment in certain circumstances where spending exceeds a certain threshold.  However, of significant concern, the hospital could require others who provide care within this “virtual bundle” to be responsible for up to 50% of full the repayment amount, including up to 25% for any one “collaborator”.

CMS states that this payment structure is designed to “give hospitals an incentive to work with physicians, home health agencies, and nursing facilities” to reduce avoidable hospitalizations and complications.  CMS also states that participants would gain access to data and educational resources to better understand post-acute care and associated spending.”

MSSNY will be working with effected specialty societies and the AMA to respond to this proposal.  Comments are due by September 8.  For more comprehensive information from CMS regarding this proposal, click here.

Is Your Infection Control Certification Up-to-Date?
New York State law requires that all health care providers—including physicians, medical residents and medical students—receive training on infection control and barrier precautions every four years upon renewal of their license.  The Medical Society of the State of New York is approved by the New York State Department of Health to provide Infection Control and Barrier Precautions to all healthcare professionals.  Additionally, MSSNY is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Measures to prevent the transmission of disease in health care settings have evolved over the years and, as such, this state-mandated course, with six elements total, includes the most updated information from the New York Department of Health.  The cost of the course is $50, payable online by credit card.  Upon successful completion of the course work, you will be able to print out your Infection Control Certificate of Completion.  Click here to take the course.

Analysis: ACA Plan Networks Offer Fewer Physicians
Health plans sold through the Affordable Care Act’s exchanges offered consumers access to 34% fewer health care providers than employer-based coverage, according to a new Avalere Health report. Avalere examined the largest rating region in the top five states by 2015 exchange effectuated enrollment: Florida, California, Texas, Georgia, and North Carolina. Compared with employer-sponsored coverage, exchange plans on average had networks with 42% fewer cancer and cardiac specialists, 32% fewer mental health and primary care physicians and 24% fewer hospitals. The study noted that the narrow networks can keep premiums low but often leave consumers with higher out-of-pocket costs. (The Hill)

PV-PQRS Users: Set up Your EIDM Account
CMS transitioned Individuals Authorized Access to CMS Computer Services (IACS) accounts to the Enterprise Identity Management System (EIDM). As of July 13, 2015, an IACS account can no longer be used to access a group or solo practitioner’s Quality and Resource Use Reports (QRURs); instead, an EIDM account will be required to access QRURs at https://portal.cms.gov. Below please find the action you should take as soon as possible in order to set up your EIDM account:

  • If you do not have an IACS or EIDM account, then follow the instructions provided here to sign up for an EIDM account with the correct role.
  • If you have an IACS account that you previously used to access QRURs, then follow the instructions provided here to sign up for an EIDM account. You will be allowed to perform the same tasks using your EIDM account that you were able to perform with your IACS account.
  • If you already have an EIDM account, then follow the instructions provided here to sign up for the correct role in EIDM.

For questions about setting up an EIDM account, please contact the QualityNet Help Desk at:

  • Monday – Friday: 8:00 am – 8:00 pm EST
  • Phone: 1 (866) 288-8912 (TTY 1-877-715-6222)
  • Fax: (888) 329-7377
  • Email: qnetsupport@hcqis.org

Additional information on accessing QRURs is available on the CMS website.



Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.


ICD10: One Year Fiscal Reprieve!!!!! – July 10, 2015

 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lg    Twitter_logo_blue1
July 10, 2015
Volume 15, Number 26

Dear Colleagues:

This week, we received news that our efforts to get some relief from the onerous outcomes for implementation of ICD-10 in October had met with positive action.  Officials at the CMS announced that for a period of one year, physicians would not incur any penalties or delays in payment as a result of incorrect use of the ICD-10 codes.

Thanks to all of you that assisted us with the efforts advanced by the Big Four (California, Florida, New York and Texas) and the AMA.  After sending the Big Four letter, we had a conference call with CMS representatives who listened to the Presidents of the four state societies as well as others.  We relayed our concerns regarding the onerous nature of implementation at a time when physicians are trying to grapple with other reform efforts.  We explained our reasoning for a two-year grace period during which physicians would have to utilize the ICD-10 codes for billing but would not be penalized for errors in the use of ICD-10 codes.  The rationale and justification seemed to resonate with CMS as we have received a grace period– albeit of one year.

The specifics of the announcement are:

  • For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes.  In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes.  This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.
  • CMS will establish an ICD-10 Ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition.
  • CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation. 

The granting of this one-year grace period does not mean our advocacy efforts are completed.  Congress is still in session and it is important we continue advocacy efforts to insure the proposed changes are implemented as regulation.  In addition, efforts are needed to attain relief from commercial payers.  .

With less than 100 days to go until the go-live date of October 1, physicians should be testing ICD-10. If not, you need to get going now. Please make the most of CMS’ one-year grace period and tap the additional resources now offered by AMA and CMS. Also, our MSSNY website offers additional resources on our home page to bring your office up to date.

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President
Please send your comments to comments@mssny.org




No Change in MLMIC Rates for 2015-2016; 5% Dividend Will Apply to Renewals
MLMIC has just been informed by DFS that they have approved MLMIC’s physician rate request for no base rate change effective July 1, 2015. There were no requested specialty or territory rate changes.  The 5% dividend can now be applied to the July 1, 2015 renewals to provide financial relief to renewing policyholders. If you have any questions please contact MLMIC at 1-888-793-0393.

CMS Proposes End-Of-Life Counseling Payment
On Wednesday, July 8, CMS stated that Medicare plans to reimburse physicians for having discussions with patients about advance care planning. The proposal, which was included in the agency’s 2016 physician payment rule, was praised by advocates and medical groups.

Dr. Patrick Conway, chief medical officer for CMS, said, “We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team.” According to the article, the plan would allow “qualified professionals like nurse practitioners and physician assistants,” as well as physicians, to be reimbursed for face-to-face consultations with a patient and any relatives or caregivers the patient chooses to include. Dr. Conway said a final decision on the proposal will be made by Nov. 1.

CMS is seeking public comment on the proposal until Sept. 8 at rule. In particular, CMS is asking for feedback on whether the payment for end-of-life conversations should be part of annual wellness exams. You may submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”

Urologist Calls for Personalized PSA Screenings for Prostate Cancer
In the New York Times (7/6, Kapoor), urologist Deepak A. Kapoor writes an op-ed calling for changes to guidelines in prostate cancer screening, which have been discouraged since 2012 for patients without symptoms of the disease. Dr. Kapoor cites improvements in screening techniques that can better predict prostate cancer risk and the need for further testing. Kapoor explains that the 2012 guidelines stemmed from the fact that prostate-specific antigen testing may lead to unnecessary surgery among patients who did not have prostate cancer or whose cancer was likely to remain dormant. He warns that an increase in prostate cancer mortality, though not yet identified, “may be a matter of time,” as “one study concluded that annual prostate cancer deaths may increase as much as 5 percent, for the first time in more than 20 years.” Finally, Dr. Kapoor recommends that men over 40 continue to pursue PSA testing and develop a personalized screening plan, rather than avoid the test altogether.

Dr. Kapoor is Chairman and CEO of Integrated Medical Professionals, a multi-specialty group of 100 physicians in the greater New York Metropolitan. IMP is one of a growing number of physician groups that have adopted a policy of 100% membership in MSSNY and their county medical societies. 

Applications Due July 31 for Physician Practice and Repayment Programs
The NYS DOH, Office of Primary Care and Health Systems Management is pleased to announce that applications for Cycle IV of the Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs will be accepted beginning July 8 through July 31, 2015.

Physician Practice Support (PPS) provides up to $100,000 in funding to support for new practices, improvements, loan repayment or other support to physicians in exchange for a two year service commitment to provide health care in an underserved region within New York State.

Physician Loan Repayment (PLR) provides up to $150,000 in loan repayment funding in exchange for a five year service commitment to provide health care in an underserved region within New York State.

Application materials can be found on the Department of Health website here.

All applications must be submitted electronically (in PDF) to gme@health.ny.gov

Questions should be directed to: Physician Practice Support-Lianne Ramos at 518-473-3513 or gme@health.ny.gov or Physician Loan Repayment: Amy Harp at 518-473-7019 or gme@health.ny.gov

Update to Physicians Advocacy Program from KACS Law Firm
Kern Augustine Conroy & Schoppmann, P.C. is proud to announce that the Physician Advocacy Program® has expanded to include the new Premier Partner Program.

The Premier Partner Program, as a stand-alone program, or an addition to your current Physician Advocacy Program® membership, will provide members with immediate access to their own expert health law defense team, in case of a legal investigation, as well as trusted advisors to build proactive solutions regarding Asset Protection, Estate Planning, HIPAA Compliance as well as Billing and Coding Documentation for reimbursement. Premier Partner Program.

CMS Proposes Revisions to Two Midnight Rule to Give Physicians More Discretion
To respond to physician and hospital concerns regarding the “two midnight rule”, CMS has proposed to allow hospitals on a case-by-case basis to receive Part A reimbursement for patients whose stay is expected to last less than two midnights.  To read the CMS release, click here.  According to the release, for stays expected to last less than two midnights – CMS proposes the following:

  • For stays for which the physician expects the patient to need less than two midnights of hospital care (and the procedure is not on the inpatient only list or otherwise listed as a national exception), an inpatient admission would be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician.  The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review.
  • CMS is reiterating the expectation that it would be rare and unusual for a beneficiary to require inpatient hospital admission for a minor surgical procedure or other treatment in the hospital that is expected to keep him or her in the hospital for a period of time that is only for a few hours and does not span at least overnight.  CMS will monitor the number of these types of admissions and plans to prioritize these types of cases for medical review.

Under the current two-midnight rule, a physician can treat Medicare beneficiaries as inpatients only when the hospital stay is expected to span two nights — from one midnight to the next — or longer.  Implementation of the rule has been delayed multiple times by Congress, including through September 30 as part of the MACRA legislation enacted this past spring.

Medicare Physician Fee Schedule on Line
Effective July 1, 2015, please be aware that the new Medicare Physician Fee Schedule is up on-line at www.NGSMedicare.com Although the increase is only 0.5%, it is an increase.  Please be sure to have your staff review the appropriate fee schedule for your locality at your earliest possible convenience.  Again, there is a 0.5% increase that became effective July 1, 2015.

Study: Medicaid Recipients Using Multiple Pharmacies Made Up Nearly Half of All Deaths Resulting From Narcotic Pain Medicine Overdose
Nearly half of all deaths resulting from an overdose of narcotic painkillers involved Medicaid recipients who used multiple pharmacies to fill their prescriptions, according to a study published in the Journal of Pain and conducted by CDC researchers. After examining “the records of more than 90,000 Medicaid recipients aged 18 to 64, who were long-term users of narcotic painkillers,” researchers found that “patients who used four pharmacies within 90 days…had the highest odds of overdosing.” http://www.jpain.org/article/S1526-5900(15)00530-1/abstract

Calling All Amateur Photogs for MSSNY’s Social Media Feeds
We’d like to include more happenings from around the state in our Twitter, Facebook and Instagram feeds. If you’re at an event that you think might be of interest to our followers, please snap a picture with your phone and send to jvecchione@mssny.org.  Be sure to include a caption or some identifying words. We’re open to any and all ideas and hope to hear from you!