August 28, 2015 – New Premiums – More for Less

NYRX
drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 28, 2015
Volume 15, Number 33

Dear Colleagues:

This week, the Wall Street Journal reported a story about rising healthcare premiums.  While President Obama expected that premium rate increase requests would come in “significantly lower” than what was then being requested, reality has proven his expectations wrong.  The story reports a premium rate increase of over 36% for a Blue Cross Blue Shield product in Tennessee. The White House rationalizes that this is still better than what was previously available.  Patients now have the option of enrolling with other products. In New York, we are beginning to realize, this usually means purchasing insurance products that offer less.  They come at a lower premium but often carry higher deductibles and have narrower networks with stringent accessing protocols.

The story reinforces the lessons I learned from my advisors and professors Bent Flyvbjerg and Paolo Quattrone when I was at Oxford.  Bent’s expertise lies in understanding why megaprojects fail to deliver on time, on budget and on-agenda.  He proposes that their failure is due to “optimism bias” and “strategic misrepresentation.” Quattrone proposes that when numbers are proposed to us in accounting reports, one should look at what is NOT being presented to understand where the real agenda lies. Accounting reports tell you what the writer wishes to tell you and not what is necessarily financially driving the organization.  These lessons are critical to understand if we are to fully comprehend where we are going on the healthcare transformation train.

Language Couches Reality

          Many, in the sincere hope of changing the flaws of our healthcare system, have succumbed to the rhetoric of the “optimism bias”— its effective language; its painted a rosy picture and emotionally evocative narratives painting an illusion of better quality and access to care.  From the trenches, we hear otherwise.  We hear the stories of patients feeling a highly impersonal healthcare engagement that is driven by process and outcomes.  The person within the patient is no longer a priority of the art of medicine, there is no art – there’s merely science and technology.

When the optimism bias is not being engaged, the more nefarious strategic misrepresentation is being utilized. Quattrone presents this as very legitimate accounting processes that artfully hide the truth of the impending dangers.  We see these every day— reports that project losses and justify premium hikes while healthcare corporate officers rake in reprehensible salaries.

How do we respond to this optimism bias, strategic misrepresentation and to the “maieutic” machine?

MSSNY is currently advocating for collective negotiations capabilities for physicians and exploring other mechanisms within safe harbor regulations that allow for greater collaboration in the efforts to bring about meaningful healthcare reform.

In the interim, each of us must individually weigh whether or not we will continue to play in the sandbox.

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

Please send your comments to comments@mssny.org


MLMIC



NYS Kindergarten Students Must Have Complete Set of Vaccinations
Effective Sept. 1, New York state pupils “entering kindergarten can no longer wait until age seven before parents demonstrate a completed series of vaccinations against highly contagious childhood infections, state health officials” announced on Aug. 27. The new rule will “require full doses of specific vaccines” before youngsters are allowed to go to kindergarten. In a statement yesterday, New York State Health Commissioner Howard Zucker, MD, JD, said, “These revisions are based on the most current science and will give our children the best protection we can provide from devastating diseases.”

NY Medical Students Honored with AMA Foundation MSSNY/Dr. Duane and Joyce Cady Physicans of Tomorrow Awards
This week, the AMA Foundation presented MSSNY/Dr. Duane and Joyce Cady Physicians of Tomorrow Awards to rising fourth-year medical students Victor Hoang, Natasha Ramsey and Michelle Smith. Each recipient was nominated by their medical school and will receive a $10,000 scholarship recognizing academic achievement.

Victor Hoang, a student at Touro College of Osteopathic Medicine, has spent summers working with Project Vietnam, building clinics and providing medical care for underserved villages in Vietnam. He has been awarded a Welch Scholars Grant in recognition of leadership, research, and academic achievement. While a student at Touro, Hoang has served as the president of the Obstetrics and Gynecology Student Organization. He earned a bachelor’s degree in molecular environmental biology from the University of California Berkeley.

Natasha Ramsey, a student at New York University School of Medicine, is pursuing a dual MD/MPH degree. She founded the Students Teaching About Real Subjects (STARS) Program, an all-girls health group dedicated to creating a safe environment to discuss topics surrounding sexual health. Ramsey also volunteers with the FOCUS program, mentoring NYU undergraduates who are first-generation college and/or minority students. Ramsey earned a bachelor’s degree in public health from Rutgers University.

Michelle Smith, a student at the University of Buffalo School of Medicine and Biomedical Sciences, was awarded the John and Janet Sung Scholarship for incoming first-year University at Buffalo medical students who demonstrate academic merit, need, and compassion for medicine. She served as fundraising chair and community service chair for the Medical Society of the State of New York (MSSNY). She led MSSNY’s partnership with St. Jude Children’s Hospital to create a statewide event benefitting New York state pediatric oncology patients. Smith graduated summa cum laude from Siena College in Loudonville, NY with a bachelor’s degree in biology.

The Physicians of Tomorrow Awards were created in 2004 to provide financial assistance to medical students facing spiraling medical school debt. On average, medical students in the U.S. graduate with a debt load of nearly $162,000. A large debt burden may deter many from practicing in underserved areas of the country or practicing primary care medicine. To date, over 1 million has been granted to exceptional medical students across the nation. 

Cuomo Announces Awards to Academic Medical Institutes
On August 27, Governor Cuomo announced $17.2 million in state awards to 26 academic medical institutions for the training of new clinical researchers working on cutting-edge biomedical research. These awards, administered over a two year period through the Empire Clinical Research Investigator Program, are vital to helping New York both attract new researchers and solidify itself as a national biomedical research hub.

Over the next two years, more than 86 physician researchers will be trained as a result of this funding in diverse research fields, including: heart and kidney disease, traumatic brain injury, human cancer genomics, health information technology, population health, and stem cell therapy. Once program researchers conclude their training through this program, they will be well prepared for careers in research.

The program supports two types of awards — team-based Center Awards and Individual Awards. Center Awards provide funding for teaching hospitals to form research teams focused on a specific topic, disease, or condition. This will not only further the development of clinician researchers, but also give these hospitals a foundation from which they can seek additional funding from the federal government to build upon their work.

Twelve institutions will receive Center Awards, with each receiving $1,260,332 over two years for the training of a team comprised of at least six fellows. For five of the 12 Center Award recipients, the awards will support both a primary and secondary project, and all 12 institutions have each committed at least $200,000 in direct matching funds for their projects.

Individual Awards are being made to 14 teaching hospitals, each of which will receive up to $150,000 over two years, to train program researchers in diverse research fields such as obesity, diabetes, lupus, kidney transplant, schizophrenia, HPV infection, and hearing loss.

The winners are as follows:

Center Awards 

  • HealthAlliance Hospital (Mid-Hudson)
  • Lincoln Medical and Mental Health Center (NYC)
  • Memorial Sloan-Kettering Cancer Center (NYC)
  • Montefiore Medical Center (NYC)
  • Mount Sinai Hospital (NYC)
  • New York Presbyterian – Columbia University (NYC)
  • New York Presbyterian – Weill Cornell Medical College (NYC)
  • North Shore University Hospital (Long Island)
  • NYU Langone Medical Center (NYC)
  • SUNY Downstate (NYC)
  • Westchester Medical Center (Mid-Hudson)
  • University of Rochester Medical Center (Finger Lakes)

Individual Awards

  • Elmhurst Hospital Center (NYC)
  • Erie County Medical Center (Western NY)
  • Hospital for Special Surgery (NYC)
  • Kings County Hospital Center (NYC)
  • Lenox Hill Hospital – North Shore LIJ Health System (NYC)
  • Long Island Jewish Medical Center – North Shore LIJ Health System (NYC)
  • Maimonides Medical Center (NYC)
  • Montefiore/New Rochelle (Mid-Hudson)
  • Mount Sinai Beth Israel (NYC)
  • New York Eye and Ear Infirmary of Mount Sinai (NYC)
  • New York Hospital Queens (NYC)
  • New York Methodist Hospital (NYC)
  • Staten Island University Hospital – North Shore LIJ Health System (NYC)
  • Winthrop University Hospital (Long Island)For more information on the Empire Clinical Research Investigator Program visit:http://www.health.ny.gov/professionals/doctors/graduate_medical_education/ecrip.

Members Only: Your Patients Can Save Up to 75% on Prescriptions
With the rising cost of both generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% onprescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!

Feds Rule that HHS Can Use Geography as Basis for Payments
Federal law gives HHS “flexibility and discretion” in calculating the reimbursement rate for providers in different geographic areas based on local wages, a federal appeals court judge has ruled on August 15.

A federal appeals court’s rejection this month of a lawsuit challenging the way the U.S. Department of Health and Human Services calculated the Medicare reimbursement rates in 2006 and 2007 sends a clear message to healthcare leaders: Don’t expect Medicare to change its ways to keep things fair.

The lawsuit was filed by 41 New England hospitals seeking $24 million in damages from what they argued were unreasonably low reimbursement rates. More specifically, the hospitals contested the HHS secretary’s decision in 2005 to change the boundaries of the geographic areas used to compute regional wage indices.

The wage indices are critical to hospital reimbursement rates because the cost of providing care can vary significantly depending on where a hospital is located, the hospitals explained in their complaint. An influential factor is the wages paid to hospital employees, which fluctuate based on the cost of living in different geographic areas.

To help compensate for those disparities, HHS annually computes a wage index that compares hospital wages within defined geographic areas to a national average, and adjusts Medicare reimbursements accordingly.

When the wage indices were computed in 2006 and 2007, the geographic boundary lines fell in a way that left three multi-campus hospitals straddling different geographic areas. Those multi-campus hospitals were deemed to be merged facilities operating as a single institution, and thus applied their combined wage data to the wage index for the main provider’s geographic area.

Groups Recommend Early Exposure to Peanuts to Prevent Allergies
A consensus statement developed and endorsed by the American Academy of Pediatrics and the American Academy of Allergy, Asthma & Immunology recommends that “infants at high risk of peanut allergies be given foods containing peanuts before they turn 1.” The recommendations stem from “a major allergy” study published this year that indicated that “exposure to peanuts in infancy seemed to help build tolerance — contrary to conventional thinking.” The statement will be published in Pediatrics.

August 26, 2015

Veterans Affairs Report: Still Not Enough Psychiatrists
A report (pdf) from the Department of Veterans Affairs’ (VA) inspector general (IG) http://www.va.gov/oig/pubs/VAOIG-13-03917-487.pdf finds that even after an extensive hiring push, the agency still has an insufficient number of full-time psychiatrists to keep up with demand and current staff is not being used efficiently.

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HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914

House

Pain Medicine Practice For Sale
Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a “turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 

Office Rental 30 Central Park South
Two  fully equipped exam, two certified operating, bathrooms and consultation room.  Shared secretarial and waiting rooms.  Elegantly decorated, central a/c, hardwood floors. Next to Park Lane and Plaza hotels. $1250 for four days a month. Available full or part-time. 212.371.0468 / drdese@gmail.com.

Home / Office – Baldwin, Nassau County, South Shore, Long Island 11510
Exceptionally well-built Split Level with 4 floors of living plus a 5-room professional suite on the ground level with a separate entrance. Office consists of a waiting room, Dr.’s consultation office, secretary’s office, 2 examination rooms plus ½ bathroom.

Home offers 3 bedrooms, 2 full plus ½ bathrooms, living room w/ vaulted ceilings, formal dining room, eat-in-kitchen, huge family room with access to a 12×17 outside enclosed porch with bluestone pavers, central air conditioning, gas heat, all hardwood flooring, fireplace, custom crafted bookcases and shelving, full finished basement and a detached 2.5 car garage. Driveway has turn-around ability with ample street parking and a municipal lot across the street. Just minuted to parkway and LIRR. Asking $439, 000. Taxes $12,000. Nancy Scarola Real Estate, Inc. 516-633-5300 Direct Cell or email nsrehomes@aol.com.

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

MSSNY eNews: August 21, 2014

NYRX
drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 21, 2015
Volume 15, Number 32

Dear Colleagues:

This past week, POLITICO reported that non-profit insurers are losing money on the Medicare Advantage products under the ACA.  Essentially, the rising cost of operations, the transitional reinsurance fee and health insurance industry fee have been blamed for company losses.  Whereas national for-profit insurers can better spread their varying regional costs of operations, constraints by the federal government on non-profit regional plans reportedly reduce these regional plans’ abilities to mitigate their losses.  These regional plans are vital as they stimulate competition in regional marketplaces.

Ironically, this summer, we have learned of three for-profit insurers (Anthem, Aetna and Centene) seeking to make acquisitions which will reduce the number of competitors in many markets.  These endeavors to consolidate by national for-profit insurers flies in the face of the ACA endeavor to promote competition.  Clearly, the attempts will test the Department of Justice in regards to upholding and interpreting anti-trust laws.

These merger and buy-out attempts come in the wake of studies that highlight just how anti-competitive the markets really are.  The December 2014 GAO Report on markets revealed that in many states, 80% of the insurance products were controlled by three insurers [GAO, Private Health Insurance, 2014].  The AMA’s 2014 study found in 41% of the metro markets studied, one insurer controlled over 50% of market [AMA, Competition in Health Insurance, 2014].

The challenges faced by the non-profit insurers in regional markets are not trivial.  Given the efforts of for-profit companies to consolidate and further control healthcare markets, it’s becoming difficult to see non-profit insurers providing a sustainable alternative to for-profit insurer products.  If non-profit insurers want to survive, it seems to me that they must recognize the value of incentivizing physicians to par with their product offerings.  Physicians have no vested interest in supporting and promoting monopsony scenarios being advanced by the for-profit insurers.  The more attractive non-profit products become to physicians, the greater the likelihood that physicians will be able to exercise individual choice and  opt out of for-profit, competition-limiting products that may be deemed by the physician to be unfair to physicians and their patients and move into competition promoting non-profit products.

Perhaps it’s time for us to reconsider a statewide IPA which could align with such non-profit payers in New York.  At the same time, we need to ramp up the call for collective negotiations legislation so as to mitigate the monopsony scenario currently fomenting.

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

Please send your comments to comments@mssny.org


MLMIC


Governor Vetoes Medicaid Managed Care Prior Approval Legislation
Governor Cuomo vetoed legislation (A.7208, Gottfried/S.4893, Hannon) passed by the New York State Legislature that would have strengthened “prescriber prevails” protections in Medicaid managed care when physicians prescribe certain medications to their patients.   In 2012, the Legislature passed a law to assure “prescriber prevails” protection for anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay or deny approval, undermining the intent of the law. The bill was seeking to fix the loopholes of this law.

The Governor’s veto message noted that:

“I remain committed to ensuring that patients receive the prescription medication recommended by their treating physicians. Current law already includes critical member protections such as rights of appeal, external appeal and fair hearing.  I have further directed the Department of Health (DOH) to respond promptly when patients or their treating physicians assert that managed care plans are preventing them from accessing their medications.

However, enacting this bill would have a significant and un-budgeted impact on the Medicaid global cap outside of the State’s budget process. This would necessarily impact other Medicaid services that may need to be reduced to accommodate this unanticipated spending. This bill would also limit managed care plans’ efforts to deter and prevent inappropriate utilization, thereby hindering the State’s ability to effectively manage pharmacy programs.  Accordingly, I am constrained to disapprove this bill.”

The bill had been supported by many patient advocacy groups.  MSSNY issued a statement that noted “We are disappointed that the bill was vetoed.  The legislation resulted from the fact that there are many physicians, most particularly psychiatrists, who have reported situations regarding Medicaid managed care plans inappropriately delaying access for medications needed by their patients.  Consistent with the veto message, we will work with specialty societies to bring these complaints to the Department of Health to address these plan abuses.”

In this regard, physicians who have experienced inappropriate delays or denials from Medicaid managed care plans in the above-listed drug classes are encouraged to share this information with MSSNY’s Division of Governmental Affairs so that we can press DOH to investigate the companies perpetrating these prior approval abuses.


Support Schumer-Crowley Legislation to Increase Residency Slots
All physicians and medical students are urged to contact their respective members of Congress in support of legislation to increase the availability of medical residency opportunities to help to address the physician shortage problem we face.  A customizable template letter can be sent from the MSSNY Grassroots Action Center here.

These efforts are part of the third annual “Save GME Action Week” where medical students from across the country will advocate for GME funding protection and expansion using legislator visits, letters, phone calls, and social media.  Their “ask” is twofold: 1) Maintain current funding for GME; and 2) Support legislation that will expand GME funding sources and the number of residency positions. MSSNY together with AMA strongly supports legislation introduced in Congress, the Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/S. 1148), sponsored by New York’s Representative Joseph Crowley and Senator Charles Schumer, to create 15,000 new residency slots to overcome the outdated cap placed in 1997.  The AMA has also created a designated advocacy page in support of these efforts, entitled www.SaveGME.org.


E-Prescribing Of All Substances Required By March 27, 2016
Physicians and other prescribers are reminded that New York State’s e-prescribing requirements for non-controlled and controlled substances will go into effect on March 27, 2016. The NYS Department of Health’s Bureau of Narcotic Enforcement has provided information to physicians and other prescribers to assist them in their transition to electronic prescribing.   Practitioners should continue their efforts to become compliant with the law, including working with their software vendors to implement the additional security requirements needed for e-prescribing of controlled substances (EPCS), and registering their certified software applications with the Bureau of Narcotic Enforcement.   According to state officials, over 22,000 prescribers have registered their systems with DOH.

For physicians who prescribe controlled substances, there are additional steps to complete in order to electronically prescribe controlled substances.  These include the following:

  • First, the software you currently use must meet all the federal security requirements for EPCS, which can be found on the Drug Enforcement Agency’s (DEA) web page. http://www.deadiversion.usdoj.gov/ecomm/e_rx/

Note that federal security requirements include a third party audit or DEA certification of the software.

  • Second, you must complete the identity proofing process as defined in the federal requirements.
  • Third, you must obtain a two-factor authentication as defined in the federal requirements.
  • Fourth, you must register your DEA certified EPCS software with the Bureau of Narcotic Enforcement (BNE). Registration instructions are included in the FAQs.

A copy of the BNE’s Frequently Asked Questions (FAQs) can be found here.

EPCS systems must be registered through the ROPES system.  ROPES stands for: Registration for Official Prescriptions and E-Prescribing Systems. To access ROPES, use the following steps:

  • Login to the Health Commerce System (HCS) at https://commerce.health.state.ny.us
  • Under “My Content” click on “All Applications”
  •  Click on “R”
  •  Scroll down to ROPES and double click to open the application. You may also click on the “+” sign to add the application “ROPES” under “My Applications” on the left side of the screen.

EPCS became permissible in New York State and over 90% of the pharmacies can now accept e-prescribing for controlled substances, according to officials from BNE.

DrFirst and MSSNY have partnered to bring MSSNY members the industry’s leading e-prescribing solution at a special discounted price. Information on this program can be found here.

There are additional venders that now have software available to e-prescribe both non-controlled and controlled substances and information on these can be found here.

There will be a waiver process for those physicians who experience technological or financial issues, however, DOH has not yet released this process, but it is expected to do so before January 1. The waiver process will be electronic.   Waivers will be provided for a facility, a large medical practice or an individual physician. The law provides that physicians may apply for a waiver of this e-prescribing requirement as a result of a) economic hardship b) technological limitations that are not reasonably within the control of the physician, or c) other exceptional circumstance.  DOH has indicated that more information on the waiver process will be available shortly.

E-prescribing of non-controlled substances is also required under the law; however, registering of this system with the state is not necessary.

The ISTOP legislation enacted in 2012 required e-prescribing of ALL substances. Regulations pertaining to the E-prescribing requirements were adopted on March 27, 2013.   The Medical Society of the State of New York was successful in obtaining a delay in the e-prescribing requirements for all substances until March 27, 2016.

Information regarding e-prescribing may be accessed at the following links:

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

http://www.op.nysed.gov/prof/pharm/pharmelectrans.htm 


AMA Foundation Presents MSSNY/Dr. Duane and Joyce Cady Scholarships
This week, the AMA Foundation presented 27  Physicians of Tomorrow scholarships, including the MSSNY/Dr. Duane and Joyce Cady Honor fund, which will provide $10,000 scholarships to fourth-year medical students. “It was a dream come true,” said Duane M. Cady, MD, the namesake of the New York honor fund and scholarships. “I only wish we could do more, especially after seeing the financial needs of the students.”

Visit the AMA Foundation website next week to view the recipient listing and biographies and learn more about the 16 honor funds.

The AMA Foundation has made it a priority to assist medical students in handling the rising cost of medical education. The Physicians of Tomorrow Awards were created in 2004 to provide financial assistance to medical students facing spiraling medical school debt. On average, medical students in the U.S. graduate with a debt load of nearly $162,000. A large debt burden may deter many from practicing in underserved areas of the country or practicing primary care medicine. To date, over 1 million has been granted to exceptional medical students across the nation.


Insurers, PBMs Consider Whether To Cover Female Libido Treatment
Bloomberg News (8/20, Edney) reports that following FDA approval, “health insurers are grappling with the question of whether to cover” Sprout Pharmaceuticals’ Addyi (flibanserin), which treats low libido in women but will have a “prominent warning label for serious side effects.”  Anthem Inc. announced Wednesday that it would cover the drug in many cases, while Cigna Corp. and Aetna Inc. are still working on their policies. PBMs Express Scripts Holding Co. and CVS Health Corp. say they are in the process of evaluating the drug.

USA Today (8/20, Ungar) reports that “it’s still unclear whether and how insurers will cover” the new treatment. Sprout Pharmaceuticals CEO Cindy Whitehead says she expects “parity coverage” from insurers between Addyi and erectile dysfunction drugs, adding that out-of-pocket costs should be similar as well. Analysts note that while PBMs are “aggressively narrowing formularies,” there could be a public outcry if insurers and employers decline to cover the drug, especially if male sexual health treatments are covered. 


STEPS Forward Initiative to Help Physicians Combat Burnout
The problem of burnout and caregiver fatigue among physicians is real and immediate. In fact, research shows that the rates of overall burnout extend to about 40 percent of U.S. physicians, more than 10 percentage points higher than the general population. In response, the AMA has created a program aimed at successfully preventing burnout and promoting well-being for medical professionals.

AMA STEPS Forward, the online practice transformation series launched last June, is offering new online modules that help physicians learn their risk factors for burnout and adopt real-life strategies to reignite professional fulfillment and resilience.


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


Members Only: Your Patients Can Save Up to 75% on Prescriptions
With the rising cost of generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!


August 26th Webinar on The Veterans Choice Program
Hear from leading Veterans Administration officials on new community-based care options, collectively referred to as the Veterans’ Choice Program, for VA beneficiaries in an AMA-hosted Webinar on August 26 from 7pm-8pm.  The AMA successfully advocated for these options to be included in the Veterans Choice and Accountability Act of 2014 to help address staffing shortages at the VA that were uncovered during last year’s scandal.

By explaining how non-VA providers can sign-up to deliver care through the Veterans Choice Program, this webinar will explain how the VA is relying on private practitioners as a short-term solution to delivery problems and workforce shortages.  Participants will understand the conditions of participation and learn how to troubleshoot claims processing issues and payment delays.  The webinar will also dispel common misconceptions about the Choice Program and the presenters will conclude with an assessment of ongoing policy challenges.  Physicians can register for the webinar here.


From Workers Compensation Re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions.  We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!

Please join us for our Fall 2015 District Dialogue Session.  This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014.  The Board plans to provide those who attend with:

  • The latest update on BPR initiatives.
  • Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.

We hope you join us at one of our District Offices.  The locations, dates and times are as follows:

  • Hauppauge
    9/1/15, 12-1 PM
    220 East Rabro Drive, Suite 100
    Hauppauge, NY 11788
    Room 116-H
  • Queens
    9/2/15, 12-1 PM
    168-46 91st Ave
    Jamaica, NY 11432
    3rd Floor, Room 325
  • White Plains
    9/3/15, 12-1 PM
    75 S Broadway
    White Plains, NY 10601
    Waiting Room
  • Buffalo
    9/8/15, 12-1 PM
    Ellicott Square Building
    295 Main Street
    Buffalo, NY 14203
    Suite 400, Room 438
  • Rochester
    9/9/15, 12-1 PM
    130 Main Street West
    Rochester, NY 14614
    Basement Conference Room
  • Albany
    9/15/15, 12-1 PM
    100 Broadway
    Menands, NY 12204
    Room 518A & 518B
  • Syracuse
    9/16/15, 12-1 PM
    935 James St
    Syracuse, NY 13203
    1st Floor-General Assembly
  • Binghamton
    9/17/15, 12-1 PM
    State Office Building
    44 Hawley Street
    Binghamton, NY 13901
    18th Floor-Warren Anderson Community Room
  • Brooklyn
    9/22/15, 12-1 PM
    111 Livingston Street
    Brooklyn, NY 11201
    22nd Floor, Room 1917
  • Manhattan
    9/23/15, 12-1 PM
    215 West 125th Street
    New York, NY 10027
    Room 511

The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact Notifications@wcb.ny.gov if you need assistance with subscribing.


 

CLASSIFIED


Pain Medicine Practice For Sale
Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a

“turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 


HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914


House

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

Aug. 14, 2015 – Join Independent Practice Task Force


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 14, 2015
Volume 15, Number 31

Dear Colleagues:

At the 2015 House of Delegates of the Medical Society of the State of New York, Resolution 210 was passed calling for the creation of a Task Force on Independent Practice. The purpose of the taskforce is two-fold. First, the Taskforce would explore viable options for independent physicians to collaborate and create practice models to achieve the goals of “diversity of service, economy of scale and collective negotiations.” Second, consult experts and examine successful independent practice models in NY and elsewhere that will facilitate the preservation of independent practice in the State of New York. We need your help!

I am looking to assemble the MSSNY team to tackle this work. This calls for physicians who have developed innovative business models of private practice as well as those who have working knowledge of practice models that can accomplish the goals of the committee. This is NOT a committee for those who want to learn on the job. Rather, it is a team of individuals who have working experience both at the individual practice level establishing new medical business ventures as well as those who have expertise through academic, business and health policy endeavors.

Is your practice unique in what it offers? Have you created an IPA? Have you written a master’s thesis on collective negotiations and messenger model negotiations? Are you a physician offering concierge services or a telemedicine based practice? Are you a physician with a law degree or an MBA that has innovated healthcare delivery for your practice in a non-traditional manner or in an innovatively thriving traditional practice? This taskforce can use your skills.

Please contact Eunice Skelly at MSSNY (eskelly@mssny.org) with a short bio and letter expressing your interest, expertise and what you intend to bring to the taskforce to advance the mission of the project. I will be looking for diversity of practice location as well as types of innovations that may contribute to a robust and comprehensive report and plan of action for preserving independent practice in New York.

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

Please send your comments to comments@mssny.org


MLMIC


MSSNY Survey Details Physician Concerns with Inadequate Health Insurance Coverage Faced By Patients
Legislators in New York and Washington D.C. must take action to assure that health insurance coverage truly provides patients with coverage for needed care, instead of a limited catastrophic benefit, according to survey results gathered by the Medical Society of the State of New York.

“The increased availability of subsidized health insurance coverage through New York’s Exchange has certainly been a positive development for our patients, but at the same time we find that more and more of our patients are underinsured due to the increasingly inadequate coverage and narrow networks offered by insurers,” said Dr. Joseph Maldonado, President of the Medical Society of the State of New York.

Many patients are surprised that the health insurance policies for which they have paid thousands of dollars per year will not cover many costs of care until they spend thousands of dollars out of pocket first.  MSSNY’s survey found that significant numbers of patients are facing deductibles imposing huge out of pocket costs before health insurers begin to pay for care.  MSSNY’s survey showed that nearly 21% of responding physicians indicated that one ¼ – ½  of their patients faced deductibles of $2,500-$5,000, and that 32% of responding physicians indicated that up to 10-25% of their patients faced deductibles of $2,500-$5,000.  Moreover, nearly 25% of responding physicians indicated that 25 to 50 % of their patients faced deductibles of $1,000-$2,500, and 36% of responding physicians indicated that up to 25% of their patients had deductibles of $1,000-$2,500.

And many physicians report that the networks that insurers offer to patients are increasingly inadequate.  Nearly 14% of responding physicians indicated that their participation contract with an insurer was not renewed in the last three years, while another 22% indicated that in the last three years they were not invited to participate in a product offering with an insurer despite participating in other products offered by that insurer.  At the same, over 45% of responding physicians indicated that they were inappropriately listed as a participating physician on a health insurer’s website in the last year, which could mask an inadequate physician network.

Even as networks shrink, so do our patients’ ability to be treated by physicians outside the network.  Over 33% of responding physicians indicated that the number of patients they treat with out of network coverage has gone down significantly in the last 3 years, while 42% noted that, for those patients who do have out of network coverage, the insurer covers a far less portion of medical portion of medical costs than they did 3 years ago.  The recent enrollment report by the New York State of Health showed that out of network coverage benefits were only available in 11 counties in New York State, and none below the Bear Mountain Bridge, since insurers have refused to offer this coverage in most areas of the State.

MSSNY is urging policymakers to review these findings closely and to make necessary changes to federal and state laws and regulations to assure health insurers offer comprehensive health care coverage as well as comprehensive physician networks.  A significant part of the problem is a provision of the ACA that enables insures to sell health insurance policies that foist up to 40% of the costs of care on patients.  MSSNY also continues to strongly urge the Legislature to enact legislation (S.1846, Hannon/A.3734, Rosenthal) to assure that our patients have the ability to purchase coverage in New York’s Health Insurance Exchange that enables them to be treated by physicians outside the plan’s network.

“What many physicians find particularly difficult to understand is that, while health insurers continue to constrain the scope of their coverage as noted by the survey results, they also continue to request significant increases in the premiums they charge to consumers and businesses,” said Dr. Maldonado.  “We urge that policymakers look closely at the policies being offered by these insurers and assure that these policies will actually provide coverage for the care needed by our patients.”


Two-Midnight Rule Enforcement Delayed Until 2016
CMS officials announced this week that it would continue to delay until the end of the year enforcement of the controversial “two midnight” rule governing short hospital stays so as to coincide with changes to the policy it recently proposed.

The two-midnight rule calls assumes a hospital admission is appropriate if the patient stays past two midnights.  The rule was adopted in response to a spike in situations of patients going into “observation status.”  Physician and hospital associations, however, have strongly opposed the rule, arguing that it undermines clinical judgment.  Implementation of the rule has been delayed numerous times, including as part of the recent SGR repeal bill until September 30.
In July, CMS proposed that the rule be modified to allow physicians to exercise judgment to admit patients for shorter stays on a case-by-case basis.  The proposal also put quality improvement organizations, or QIOs, in charge of initial reviews of the appropriateness of short inpatient hospital stays, rather than Medicare Administrative Contractors.

For more information, read here:


MSSNY Survey: EHR Usage Shows Continued Frustration with EHR Technology
As government increasingly seeks to condition physician payments on the achievement of hard to define cost efficiency and quality targets, it has decreed meaningful use of electronic health records an essential component of demonstrating quality care.

While this technology holds great promise to enhance care delivery, many physicians across New York and across the country have identified numerous obstacles to successfully incorporating EHR technology into their practice workflow, sometimes interfering with the delivery of patient care.

MSSNY’s HIT Committee has prepared a survey to elicit your thoughts on how EHR functionality could be improved including identifying areas on which additional educational programs would provide meaningful value for practicing physicians.

Please take a couple of minutes to provide your insight on these very important topics.

Please click here to take the survey.


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.


From Workers Compensation re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions.  We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!

Please join us for our Fall 2015 District Dialogue Session.  This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014.  The Board plans to provide those who attend with:

  • The latest update on BPR initiatives.
  • Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.

We hope you join us at one of our District Offices.  The locations, dates and times are as follows:

  • Hauppauge
    9/1/15, 12-1 PM
    220 East Rabro Drive, Suite 100
    Hauppauge, NY 11788
    Room 116-H
  • Queens
    9/2/15, 12-1 PM
    168-46 91st Ave
    Jamaica, NY 11432
    3rd Floor, Room 325
  • White Plains
    9/3/15, 12-1 PM
    75 S Broadway
    White Plains, NY 10601
    Waiting Room
  • Buffalo
    9/8/15, 12-1 PM
    Ellicott Square Building
    295 Main Street
    Buffalo, NY 14203
    Suite 400, Room 438
  • Rochester
    9/9/15, 12-1 PM
    130 Main Street West
    Rochester, NY 14614
    Basement Conference Room
  • Albany
    9/15/15, 12-1 PM
    100 Broadway
    Menands, NY 12204
    Room 518A & 518B
  • Syracuse
    9/16/15, 12-1 PM
    935 James St
    Syracuse, NY 13203
    1st Floor-General Assembly
  • Binghamton
    9/17/15, 12-1 PM
    State Office Building
    44 Hawley Street
    Binghamton, NY 13901
    18th Floor-Warren Anderson Community Room
  • Brooklyn
    9/22/15, 12-1 PM
    111 Livingston Street
    Brooklyn, NY 11201
    22nd Floor, Room 1917
  • Manhattan
    9/23/15, 12-1 PM
    215 West 125th Street
    New York, NY 10027
    Room 511

The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact Notifications@wcb.ny.gov if you need assistance with subscribing.


Members Only: Your Patients Can Save Up to 75% on Prescription
With the rising cost of both generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!

The August 4th edition of The Daily included a Huffington Post blog by Paul Alexander (“Is New York’s Education Department Making the Doctor Shortage Worse?”) that reported erroneous information about the New York State Education Department (NYSED)’s policy regarding clerkships for international medical students.  MSSNY spoke to Steve Boese, Executive Secretary of the Board for Medicine at the NYSED, who said the information in the Huffington Post blog is incorrect and that no prohibition on clerkships has been put in place.


Clarifying Questions & Answers Re ICD-10 Flexibilities 

 Question 1:

When will the ICD-10 Ombudsman be in place? 

Answer 1:

The Ombudsman will be in place by October 1, 2015. 

Question 2:

Does the Guidance mean there is a delay in ICD-10 implementation? 

Answer 2:

No.  The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization.  Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code.  The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims. 

Question 3:  

What is a valid ICD-10 code? (Revised 7/31/15)

Answer 3:

All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service.  ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity.  A three-character code is to be used only if it is not further subdivided.   While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.

An example is C81 (Hodgkin’s lymphoma) – which by itself is not a valid code. Examples of valid codes within category C81 contain 5 characters, such as:

C81.00  Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site

C81.03    Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes

C81.10    Nodular sclerosis classical Hodgkin lymphoma, unspecified site

C81.90    Hodgkin lymphoma, unspecified, unspecified site

During the 12 month after ICD-10 implementation, using any one of the valid codes for Hodgkin’s lymphoma (C81.00, C81.03, C81.10 or C81.90) would not be cause for an audit under the recently announced flexibilities.

In another example, a patient has a diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus).  Use of the valid codes G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus) instead of the correct code, G43.711, would not be cause for an audit under the audit flexibilities occurring for 12 months after ICD-10 implementation, since they are all in the same family of codes.

Many people use the terms “billable codes” and “valid codes” interchangeably.   A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is needed.  Using this free list of valid codes is straightforward.  Providers can practice identifying and using valid codes as part of acknowledgement testing with Medicare, available through September 30, 2015. For more information about acknowledgement testing, contact your Medicare Administrative Contractor, and review the Medicare Learning Network articles on testing, such as SE1501. 

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4:

Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims. 

Question 5:  

What is meant by a family of codes? (Revised 7/31/15) 

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Another example, K50 (Crohn’s disease) has codes within the category that require varying numbers of characters to be valid.  The ICD-10-CM code book clearly provides information on valid codes within this, and other categories.  And if in doubt, providers can check the list of valid 2016 ICD-10-CM codes to determine if all characters have been selected and reported.  Examples of valid codes within category K50 include:

K50.00  Crohn’s disease of small intestine without complications

K50.012 Crohn’s disease of small intestine with intestinal obstruction

K50.90    Crohn’s disease, unspecified, without complications

To include the Crohn’s disease diagnosis on the claim, a valid code must be selected.   If the paid claim were to be selected later for audit, the Guidance makes it clear that the claim would not be denied simply because the wrong code was included, so long as the code was in the same family.  As long as the selected code was within the K50 family, then the audit flexibility applies. 

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations.  (See Question 7 for more information about this).  This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected.  The physician can resubmit the claims with a valid code. 

Question 7:  

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required.  Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

Answer 7:

No.  As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review 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 of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.  It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9.  LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side.  The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/. 

Question 8:

Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

Answer 8:

Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Question 9:

Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

Answer 9:

No, the audit and quality program flexibilities only pertain to post payment reviews.  ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests. 

MEDICAID

Question 10:  

If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?     

Answer 10:

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner.  Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met.  If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare.  Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Question 11:  

Does this added ICD-10 flexibility regarding audits only apply to Medicare?  

Answer 11:   The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Question 12: 

Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes? 

Answer 12:

Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

OTHER PAYERS

Question 13: 

Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

Answer 13:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule.  Each commercial payer will have to determine whether it will offer similar audit flexibilities.

CMS has recently agreed to hold listening sessions with physician organizations on two sections of the Medicare Access and CHIP Reauthorization Act (MACRA). The next session will address the alternative payment models provisions in MACRA, and will be held on August 19 from 10:30 am to noon Eastern.  DC-based specialty staff will participate in person from the AMA’s Washington office but we are also arranging a call-in line for participation in both meetings by state medical society staff.  A CMS slide deck laying out the MIPS section of the law along with a set of questions is attached.  We expect to have questions to be addressed at the August 19 meeting soon and will send those out as well.  In order to ensure that we have enough phone lines, we ask that if multiple people from the same state plan to participate in the call, they all gather at the same location and use a single phone line.  The call-in line is 866-740-1260.  The access number is 7897464.


MLN Connects National Provider Call: Countdown to ICD-10

Thursday, August 27; 2:30-4 pm ET

To Register: Visit MLN Connects Event Registration. Space may be limited, register early.

Don’t miss the August 27 MLN Connects Call — five weeks before ICD-10 implementation on October 1, 2015. CMS Acting Administrator Andy Slavitt will be opening the call with a national implementation update. Then, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) will be joining us with coding guidance and tips, along with updates from CMS.

Agenda:

  • National implementation update, CMS Acting Administrator Andy Slavitt
  • Coding guidance, AHA and AHIMA
  • How to get answers to coding questions
  • Claims that span the implementation date
  • Results from acknowledgement and end-to-end testing weeks
  • Provider resources

Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, skilled nursing facilities, home health agencies, and all Medicare providers.

Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.


CLASSIFIED


Pain Medicine Practice For Sale
Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a

“turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 


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.


HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914


House

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

Aug. 7, 2015: Other payers position’s on CMS’ relaxed ICD-10-CM rules


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 7, 2015
Volume 15, Number 30

Dear Colleagues:

Earlier this year, the Commonwealth Fund reported the findings of its 2014 Biennial Health Insurance Survey. It subsequently published a brief on the growing trend of Americans purchasing inadequate insurance coverage. The brief notes that the “share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014”.   It further reports that 23 percent of 19-to-64 year-old adults (31 million) had high out-of-pocket costs or deductibles and were as such, underinsured.  This stands in contrast to the 17 million that were previously uninsured who now have insurance (regardless of its adequacy).  The Commonwealth Fund sounds the alarm calling attention to the problem of the underinsured.

This comes as no surprise to New York’s physicians. Many of MSSNY’s members have been sounding this alarm for several years. The numbers of individuals who, prior to the ACA, had no health insurance has decreased.  But the number of those previously insured with higher deductible plans has increased.  This poses a tremendous burden on both patients and physicians.  The Commonwealth Fund brief notes that more such patients are seeing their credit ratings drop, experiencing bankruptcy and incurring credit card debt to pay their deductibles.

Physicians are required by law to make a reasonable effort to collect payment from patients.  We cannot simply write off the physician charges as bad debt.  For the patient who does not meet their high deductible, failure to meet their deductible obligation to their physician threatens future access to care (57% of patients with a high deductible plan reported at least one cost-related access problem).  Many physicians complain to me about their dilemma in trying to render necessary care–despite the patient’s inabilities to meet their deductible–while maintaining viable practices.  For many, opting out of high-deductible plans or opting out of a particular carrier is the only option for their financial viability.

If we truly want to improve access to care for all Americans, we must design health policies that ensure that ALL Americans have access to care.  This means designing and promoting healthcare insurance products with affordable deductibles that encourage patients to seek care and ensure a full cadre of participating physicians to meet their needs.

Failure to address this problem will destroy America’s middle class and shift the demographics of poor health outcomes from America’s poor to America’s middle class.

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

Please send your comments to comments@mssny.org


MLMIC


SIM/SHIP Listening Tour Sessions in NYC, LI and Albany Next Week: This is Your Opportunity to Participate!
The Department of Health is conducting a Listening Tour to receive input on its design and rollout of the State Innovation Model/State Health Innovation Plan (SIM/SHIP) which will facilitate accelerated delivery system transformation to provide better care at lower cost. Several of MSSNY leaders participated in the SIM listening Tour sessions held last month in Buffalo, Rochester and Syracuse. The SIM/SHIP Tour will hold sessions for physician leaders in NYC, LI and Albany next week! This is your opportunity to participate!

This is a very important opportunity for physicians to provide feedback to the Department of Health on the State Innovation Model (SIM) and the various aspects of the Advanced Primary Care Model. In order to ensure that there is input from our members, you are being invited to participate.

The meeting locations are listed below.  If you are interested in participating, please contact Liz Dears at ldears@mssny.org. Due to space limitations registration is required.

NYC Provider Listening Session:

Date:     8/10/15

Time:    10:00 am – noon

Venue:  United Hospital Fund

1411 Broadway, 12th Floor
New York, NY 10018

Long Island Provider Listening Session:

Date:     8/11/15

Time:    10:00 am – noon

Venue: Medical Liability Mutual Insurance Company (MLMIC)

90 Merrick Avenue – 7th Floor
East Meadow, New York 11554

 Albany Provider Listening Session:

Date:    8/12/15

Time:    10 am – noon

Venue:  MSSNY

99 Washington Avenue, Ste 408

Albany, NY 12210 


MSSNY Survey on EHR Usage and Functionality Shows Continued Level of Frustration with EHR technology- Physicians Who Haven’t Yet Done So, Urged to Complete Survey
Preliminary response to MSSNY’s survey on EHR usage and functionality are consistent with results of other surveys which show a level of dissatisfaction with regard to EHR systems.

While 78% of respondents to MSSNY’s survey are using or plan within two years to use EHRs in their practice or at their hospital, 53% stated that they are either disappointed or very disappointed with their EHR. Notably, 38% of the respondents stated that their EHRs cannot generate routine reports to help manage their patient population, like diabetics, hypertension or ad hoc reports like finding patients due for a flu shot and 29% replied that their EHRs do not support meaningful use 2 or provide guidance on how to achieve MU-2. 56% responded that their EHR did not have prompts to notify them of gaps in patient care. Of the 45% of physicians who stated that they were currently participating in pay for performance (P4P) programs that require reporting from their EHRs, 32% stated that their EHR did not give adequate support to collect data to support their P4P program.

Many stated that they or their staff either manually aggregated the data or purchased additional software to do so. 75% of the respondents did indicate that they were e-prescribing either non-controlled substances only (46%) or both non-controlled and controlled substances (29%). Of those who were not e-scribing, a majority (66%) indicated that the delay in the implementation of the law was the primary reason why they were not yet e-scribing. With regard to educational programming, 46% of respondents stated that they would like more information on three topics: the Delivery System Reform Incentive Program (DSRIP) and how it will affect my practice;  the State Health Innovations Plan and how will it affect my practice; and how to get the most out of the data in your EHR. Other educational programs thought to be of value to respondents included: Value Based Purchasing; What is It and how can physicians position themselves to maximize payment (40%) and Practice transformation; what does this accomplish for the typical physician practice (33%).

Physicians are encouraged, if they haven’t yet done so, to complete the survey by clicking here.


Contact Governor Cuomo to Help Assure “Prescriber Prevails” Protections
Physicians are urged to contact the Governor’s office in support of legislation (A.7208, Gottfried/S.4893, Hannon) that would strengthen “prescriber prevails” protections in Medicaid managed care.  The bill passed the Assembly and Senate before the end of Session, and was just sent to the Governor.

The bill would reduce the hassles physicians are experiencing in trying to assure their patients insured by MMC plans can receive necessary anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications.  In 2012, the Legislature passed a law to assure “prescriber prevails” protection for these drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay approval, undermining the intent of the law.  This legislation would help to assure patients can receive these medications with a minimum of hassles.

The Governor has until next Friday, August 14, to act on the bill, so contacts must be made in the next week. A letter can be sent from the MSSNY Grassroots site here or a call can be made to 518-362-8946.


Legionnaires’ Outbreak Has Infected 100, Killed 10
As of Thursday, the Legionnaires’ disease outbreak in New York City has sickened at least 100 individuals. Ninety-two people have been hospitalized and 48 have been treated for the disease and discharged, according to the city’s Department of Health and Mental Hygiene. New York City Health Commissioner Dr. Mary T. Bassett issued a directive Thursday calling for all New York City buildings with water-cooling towers to be accessed and disinfected within the next two weeks. Today, Mayor Bill de Blasio is expected to provide details of a legislative plan he announced this week that is meant to tighten regulation of the cooling towers.


CMS Revised Guidelines Regarding ICD-10 Flexibilities
CMS has revised their FAQs on ICD 10 coding, which are consistent with the original announcement regarding flexibility when the right “family of codes” are submitted. Revisions were made to questions 3 and 5. We are also working with CMS to develop a version of the FAQs that is specifically geared for physicians (attached document is aimed at multiple audiences—Medicare contractors, CMS regional offices) and to be sure that a teleconference planned for late August reflects the initial joint announcement issued on July 6.


ICD-10 News from Non-Medicare Payers
Regina McNally, VP of Socio-Med, has asked non-Medicare payers their view of the AMA’s and CMS’ “relaxed rules” regarding the one-year grace period while physicians transition to full ICD-10 implementation. The following are the non-Medicare payers responses received to date:

  • Aetna: here for Aetna guidelines
  • Cigna: Click here for Cigna guidelines
  • Excellus: “There has been no official decision or discussion on this matter to date.  I suspect we will be following CMS.”
  • HealthPlus/Amerigroup: HealthPlus is evaluating CMS’s guidance for Medicare Part B and its applicability/impact to Medicaid. Consequently, we are awaiting additional guidance from CMS, as to how the agency defines “family” of codes and any guidance specific to Medicaid and Medicare Advantage.  CMS indicated additional guidance is to be forthcoming.
  • Magna Care: http://www.magnacare.com/icd/icd.aspx
  • Medicaid: We are working with CMS and are being advised that they will be issuing guidance to state Medicaid agencies sometime next week.  If you have received or seen anything from CMS it would be great if you could share.  I’ll continue to monitor from our end.
  • MVP: posts its approach and guidelines towards the ICD-10 transition online.  Here is the link. https://www.mvphealthcare.com/provider/ICD-10_updates_and_faqs.html
  • Oscar: We are fairly confident that we will go by this policy for ICD-10: Claims with date of service after 10/1 must have ICD-10 or they will be  Claims received after 10/1 but with date of service before 10/1 can be in ICD-9. For your questions related to a grace period for mis-coded claims, this isn’t a decision that’s been finalized. My sense is that giving providers 365 days to correct a claim is probably too long. We’ll likely stick with our current policy which allows providers to submit an adjusted claim in X number of days after getting a claim decision. X being the number of days a provider has to submit an initial claim. So if a provider has 120 days to submit an initial claim, they’ll have 120 days after getting a claim decision from us to submit an adjusted claim if they feel they made a mistake.
  • SEIU 1199: “For outpatient claims, the 1199SEIU Benefit Funds will deny claims with dates of service on or after October 1, 2015 that is billed with ICD-9 codes.   We will not deny claims if they are submitted with a valid ICD-10 CM and will not deny claims for proper or specificity coding.  Providers can submit corrected claims within 180 days of denials/payment if needed.  For Inpatient Hospital Claims, 1199SEIU Benefit Funds will expect that hospitals apply specificity coding to assign the appropriate DRGs.  Inpatient claims are subjected to reviews to validate this.”
  • UHC: At this point UnitedHealthcare does not believe that any change in our plans is required. The CMS-AMA guidance is specific to Medicare Part B and to medical record reviews / reporting penalties. Actual claim submission (valid ICD-10 code is required for submission) and claim processing should not change (either with CMS or elsewhere). Also, CMS has not issued any additional or modified requirement to health plans regarding ICD-10 claim processing.

Subsequently, when UHC was asked: if Medicare is primary and the physician used an unspecified code within the Family of ICD-10 and Medicare extended their primary benefit, will UHC extend its secondary benefit involving the Medicare deductible and/or coinsurance?  UHC’s replied as follows:

It would still have to be a valid code—not the family code—for CMS submission.  The code submitted can be unspecified, as unspecified codes are valid codes (it should be said that UnitedHealthcare is aligned with the CMS guidance from a specificity perspective in the sense that we do not have a new edit related to ICD-10 specificity) but again it has to be a valid ICD-10 code.  Below is what CMS states about valid codes:

What is a valid ICD-10 code? (Revised 7/31/15)

Answer 3:

All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.

Question 5:

What is meant by a family of codes? (Revised 7/31/15)

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.


Emblem Health Response to 7/31 Enews Article: Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
We [Emblem Health] convened a meeting (in follow-up to my forwarding your email) with representation from our Recovery Unit, Medical Directors and Legal department to ensure that all understand that CMS rescinded the MLN SE 1315 document and that it can no longer be used as grounds for recoveries. (We also confirmed that all of the requests that had been made were within the correct look back periods.) A new communication is being prepared to the providers who received the notices.

Regarding the larger issue of the use of Modifier 25, the joint understanding of the group is that it is necessary as the way for providers to let us know that a separate and distinct Evaluation and Management (E&M) service took place in addition to the diagnostic test or procedure. We agree that both events can take place on the same day and that both events can be payable, but they need to be communicated to us in a way that we can distinguish situations where the test or procedure was the sole reason for the visit from those situations where the test or procedure was performed in addition to a discrete E&M service.  According to our Medical Director, visits for “tests only” take place all the time and use of Modifier 25 is a matter of correct coding, not how medicine is practiced.

Emblem Health is planning an education campaign to let providers know that they need to distinguish stand-alone E&M services by using Modifier 25.

For Nassau and Suffolk Physicians


Adelphi University Accelerated MBA Program for Physicians
The Suffolk County Medical Society (SCMS) has formed a partnership with Adelphi University to offer its physician members (and prospective members) an opportunity to obtain an MBA degree from the Robert B. Willumstad School of Business. All classes will be held at SCMS headquarters.

All coursework is related to healthcare and will help you to run a more cost-effective practice as well as become proficient in business strategies. You’ll also gain the necessary skills to be an effective leader, critical thinker, negotiator and problem solver should you choose to be part of the decision-making process in the future of the healthcare system.

Classes will meet on Thursday evenings at SCMS, 1767 Veterans Memorial Highway in Islandia. The program will consist of 42 credits (14 courses) and is AACSB Accredited. For more information about the program, please contact Maureen Leslie, Assistant Director, at 516-237-8607 or leslie@adelphi.edu.



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