Dr. Joseph R. Maldonado
September 11, 2015
Volume 15, Number 34
Yesterday, the New York Times published a letter to the editor written by Ken Raske, president of the GNYHA and me. The original op-ed, written by two attorneys, supported Lavern’s Law which sought expansion of dates of discovery.
To the Editor:
Re “Legislative Malpractice,” by Thomas Moore and Steve Cohen (Op-Ed, Aug. 31):New York’s medical malpractice system needs comprehensive reforms. The writers note that many states allow patients to file suit based on when they discover that there was a medical error, but, unlike New York, most of those states also have caps on damages and other laws that balance the effects of wider discovery rules. Pegging New York’s statute of limitations to a patient’s subjective knowledge will potentially lead to far more claims and greater financial exposure for the state’s doctors and hospitals.
Despite scoring high on various quality indicators, New York’s hospitals and doctors have among the highest medical malpractice costs in the United States. Many doctors logically conclude that the state is simply too hostile an environment to practice medicine.
Finally, the same study that the writers cite to blame hospitals and doctors (“To Err is Human”) emphasizes that improving patient safety requires a shift away from a culture of blame. Other studies have concluded that the drivers of malpractice liability are varied and not necessarily related to the quality of care.
Medical malpractice is a complex issue that deserves thoughtful discourse. Only through comprehensive reform — not narrow, piecemeal legislation — can we achieve appropriate balance and minimize inequities.
KENNETH E. RASKE
JOSEPH R. MALDONADO Jr.
The writers are presidents of the Greater New York Hospital Association and Medical Society of the State of New York, respectively.
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Excellus BCBS Target of Cyberattack; 7M People Affected
On Sept. 9, Excellus BlueCross BlueShield announced that its Information Technology (IT) systems were the target of a sophisticated cyberattack and steps are being taken for the protection of its members and individuals who do business with the health plan.
As a result of cyberattacks on other insurance companies, Excellus BCBS engaged FireEye’s Mandiant incident response division, one of the world’s leading cybersecurity firms, to conduct a forensic assessment of its IT systems. On August 5, 2015, Excellus BCBS learned that cyber attackers gained unauthorized access to its IT systems.
The investigation has not determined that personal information on the company’s IT systems was removed or used inappropriately. However, the investigation has determined that attackers may have gained unauthorized access to approximately 7 million individuals’ information, which could include name, date of birth, Social Security number, mailing address, telephone number, member identification number, financial account information and claims information.
Excellus BCBS is beginning to mail letters to affected individuals today and is providing two years of free identity theft protection services through Kroll, a global leader in risk mitigation and response solutions, including credit monitoring powered by TransUnion. A dedicated call center also has been set up for members and other affected individuals. And, the company has established a dedicated website (www.excellusfacts.com), where members and other affected individuals can view frequent questions and answers and sign up for the free credit monitoring service and identity theft protection services. Individuals who believe they are affected by this cyberattack but who have not received a letter by November 9, are encouraged to call the number listed at that website.
WCB Issues Guidance for Complying With ICD-10 as of October 1
The New York State Workers Compensation Board today issued a bulletin to set forth how it will implement the use of ICD-10 codes as of October 1. To read the bulletin, click here.
The bulletin notes that “to promote consistency between medical systems and to avoid imposing significant costs to support multiple systems, the Board will require use of ICD-10 consistent with CMS for dates of service after 10/1/15. In particular, the Bulletin notes the following:
• Providers may not submit a combination of ICD-9 and ICD-10 codes on the same bill. Separate bills must be submitted for dates of service on or before September 30, 2015 and on or after October 1, 2015.
• In the event a provider has not completed the full transition to ICD-10, medical bills shall be processed and paid regardless.
• Carriers must accept both ICD-9 codes and ICD-10 codes effective October 1, 2015. Provider miscoding, such as the use of ICD-9 codes for dates of service on or after October 1, 2015, or the use of ICD-10 codes for dates of service prior to October 1, 2015, are not valid reasons to deny or reduce a medical bill.
• In order to ease the transition to ICD-10, the Board will accept the CMS-1500 (or HCFA-1500) form with a detailed narrative report or office note effective October 1, 2015. Authorized physicians, podiatrists, and chiropractors statewide may submit a CMS-1500 with a detailed narrative report or office note in lieu of C-4 or C-4.2 forms. If a CMS-1500 is submitted without the detailed narrative report or office note, it is not a valid bill submission. A narrative report or office note is considered detailed when it contains the necessary information for the insurance carrier to properly process the submission. The narrative attachment requirements can be found on the Board’s website.
Dr. Maldonado: More Mergers Provide Less Choice
The transition from five major health insurers to three would “erode competition” across the country in major metropolitan markets, including New York, the American Medical Association said yesterday. The Chicago group asserts that the Anthem-Cigna and Aetna-Humana mergers would slash competition in 154 metro areas in 23 states. Only the Anthem-Cigna union would have a notable impact on New York’s commercial insurance market, according to the AMA analysis: Competition in the combined HMO, PPO and POS markets would fall about 12%. The report used a method to measure market competition called the Herfindahl-Hirschman Index. The Anthem-Cigna deal would give the state an HHI score of 1,921—still well within the range of a moderately concentrated market. Scores below 1,500 are considered unconcentrated, and, above 2,500, highly concentrated. The mergers “will give these companies far greater market power to reduce physician and hospital choice for our patients receiving needed care,” said Dr. Joseph Maldonado, president of Medical Society of the State of New York. (Crain’s 9/9/15)
Key New York Congressman Backs Fair Medicare Audits Legislation
Western New York Congressman Chris Collins has joined on as a co-sponsor of HR 2568, for the Fair Medical Audits Act of 2015, legislation supported by several state medical societies to increase the transparency of Medicare Recovery Audit Contractor (RAC) audits. Rep. Collins is a member of the US House of Representatives Energy & Commerce Health Subcommittee. As noted by the Physicians Advocacy Institute, the legislation, sponsored by Rep. George Holding (R-NC), would:
- Makes the audit process much more transparent. The FMAA requires RACs to provide pre-audit notification and post audit reporting to physicians and other health care providers regarding specific information relating to an audit. Increasing transparency will help address confusion and create a more educational audit process by helping physicians to better understand audit findings and reduce the risk of repeated errors.
- Establishes more rigorous qualifications for RAC officials performing claim reviews. The complex nature of medical audits and the need to address the high reversal rate for appealed overpayment determinations warrant more rigorous qualifications for RAC reviewers.
- Increases accountability of RACs for Inaccurate findings. The current system is a bounty hunter approach that creates financial incentives for auditors to make overzealous and often-inaccurate audit findings. FMAA establishes financial penalties for RACs for inaccurate audit findings, while creating new incentive payments for RACs who voluntarily educate providers on common errors.
- Delays payment to auditors until after an external appeal. The FMAA would delay RAC payments until claims are subject to external review – currently the third level of appeal – to help ensure providers are not subject to premature and unfair recoupment.
- Promotes more targeted documentation requests by RAC auditors. Physician practices have struggled with the administrative and financial burdens that RAC correspondence and production requests often impose. The FMAA would help to address this by compensating providers for certain documentation requests.
- Requires a sound extrapolation formula for determining overpayment amounts and shortens “look-back” period from 4 years to 2 years. Shortening the look-back period to 2 years would more effectively address the appeals backlog and provide much-needed administrative relief for providers.
Press-Ganey: Patients Like Healthcare Teamwork and Clean Rooms
A health care team’s ability to work together is a major factor in hospital inpatient ratings linked to loyalty, according to an analysis more than 1 million HCAHPS responses by Press Ganey, the largest patient-experience consulting firm http://bit.ly/1KHJnS8
Of inpatients who believed staff worked well together, 87% gave their experience high ratings;36.7% of patients who did not think staff were coordinated gave top ratings overall. In hospitals, once teamwork was accounted for, room cleanliness emerged as a major ratings driver. Regarding emergency room care, empathy for patient concerns and communication about delays and pain management were most highly related with a patient’s likelihood to recommend the facility. In outpatient facilities, confidence in the clinician, along with effective care coordination and empathy, were paramount.
AMA Report Highlights Concerns of Proposed Health Insurer Consolidation, including New York; MSSNY Issues Statement
The American Medical Association released a study this week raising an alarm with the significantly enhanced health insurer market concentration that would arise within14 states across the country, including New York State, if the recently announced proposed merger of Anthem and Cigna was permitted to go forward. To read more, click here. The report also discussed the enhanced market concentration in several states across the country as a result of the proposed merger of Aetna and Humana, though no specific consequences for New York State were noted.
The report and its possible consequences on patients and physicians were highlighted in an article in the New York Times.
Moreover, the issue of the consequences of insurer consolidation was the subject of a House Judiciary Committee hearing this week.
The AMA report noted that the proposed Anthem-Cigna merger would be presumed to significantly enhance the market power of the combined company for the entire commercial market in Long Island, as well as raising significant competitive concerns in New York City and the Hudson Valley. As a result, MSSNY President Dr. Joseph Maldonado gave the following press statement which was reported in Politico New York and Crains’ Health Pulse regarding the need to better level the playing field between market dominant insurers and physicians advocating on behalf of their patients:
“Today’s announcement by the American Medical Association analyzing the consequences of the proposed consolidation of the health insurance industry is a clarion call to our federal and state regulators to closely review the patient care implications of these proposed mergers.
Undoubtedly, the mergers of Anthem (the parent of Empire BC/BS) with Cigna, and Aetna with Humana, will give these companies far greater market power to reduce physician and hospital choice for our patients by further restricting networks and moving towards more burdensome administrative requirements as a precondition of our patients receiving needed care.
In addition to preventing these mergers from going forward, policymakers need to enable physicians to better advocate on their patients’ behalf by enacting legislation (A.336, Gottfried S.1157, Hannon) to permit independently practicing physicians to come together to negotiate patient care terms with health insurers in regions where just a few plans dominate the delivery of care.”
“Many Faces of Flu” CME Webinar on October 21; Registration Now Open
MSSNY will begin its 2016 Medical Matters continuing medical education (CME) webinar series with “Many Faces of Flu 2015” on Wednesday, October 21, 2015 at 7:30 a.m. William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program. Registration is now open for this webinar here.
Educational objectives are: 1) Recognize the distinction between seasonal, Avian and Pandemic flu; 2) Describe clinical and laboratory diagnostic features and treatment; 3) Identify recommended immunizations and antiviral medications for treatment. The Medical Society of the State of New York is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA/PRA Category 1 credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Medical Matters is a series of CME webinars sponsored by MSSNY’s Committee on Emergency Preparedness and Disaster/Terrorism Response. Additional programs will be conducted in January-May 2016 and topics include: public health preparedness; immunizations and recommendations during a disaster; and radiological emergencies. Program dates for Medical Matters will be announced shortly.
Get Ready Now: Assess How ICD-10 Will Affect Your Practice
With ICD-10 less than 30 days away, now is the time to get ready. You can make sure your practice is prepared by following the ABCs of ICD-10:
- Assess how ICD-10 will affect your practice and make a plan
- Be sure your systems are ready
- Contact your vendors
Access to ICD-10 codes – You can find codes from a variety of sources, including:
- Code books
- CD/DVD and other digital media
- Online (e.g., go to cms.gov/ICD10 and select “2016 ICD-10-CM and GEMS” to download 2016 Code Tables and Index)
- Practice management systems
- Electronic health record (EHR) products
- Free and low-cost smartphone apps
- CMS ICD-10 Code Lookup
- Coding Conversion Tool
Clearinghouse services – Some providers who are not ready could benefit from contracting with a clearinghouse to submit claims.
- Clearinghouses can help by:
- Identifying problems that lead to claims being rejected
- Providing guidance about how to fix rejected claims (e.g., more or different data need to be included)
- Clearinghouses cannot help you code in ICD-10 codes unless they offer third-party billing/coding services.
- Train staff on ICD-10 fundamentals using the wealth of free resources from CMS, which include the ICD-10 website, Road to 10, Email Updates, National Provider Calls, and webinars. Free resources are also available from:
- Medical societies, health care professional associations
- Hospitals, health systems, health plans, vendors
- Training for clinical staff—e.g., physicians, nurse practitioners, physician assistants, registered nurses—should focus on documentation, new coding concepts captured in ICD-10.
- Training for coding and administrative staff—e.g., coders, billers, practice managers—should focus on ICD-10 fundamentals.
Systems upgrades – Double check that you’ve identified all systems that use ICD codes and need upgrades (e.g., practice management systems, electronic health record (EHR) products).
- Call your vendors to confirm the ICD-10 readiness of your practice’s systems
- Confirm that the health plans, clearinghouses, and third-party billing services you work with are ICD-10 ready
- Ask vendors, health plans, clearinghouses, and third-party billers about testing opportunities
- Transition costs for small medical practices could be substantially lower than projected earlier:
- Many EHR vendors are including ICD-10 in their systems or upgrades—at little or no cost to their customers
- Software and systems costs for ICD-10 could be minimal for many providers\
NYS DOH Announces New Vaccine Rules for Children Entering School
The NYS-DOH announced new vaccine rules for school children. Children in New York schools must now receive two doses of the measles, mumps, rubella vaccine, before entering school. Children in grades K-5 need five doses of DTaP, and children entering kindergarten and grades 1, 6 and 7 must have four doses of polio vaccine. Previously, kindergarteners were allowed to attend school before completing the MMR DTaP and polio vaccine series. The new regulations follow recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP). A physician letter on these changes was issued on August 26, 2015 from Elizabeth Rausch-Phung, MD, MPH, NYS DOH, Director, Bureau of Immunization and is available here. Additional information on the regulatory changes may be obtained here.
CMS Releases 2014 QRURs and PQRS Reports
On September 9, 2015 CMS released the 2014 Quality and Resource Use Reports (QRURs) and 2014 Physician Quality Reporting System (PQRS) Feedback Reports. The 2016 PQRS and Value Modifier (VM) payment adjustments are based on 2014 reporting. For groups with 10 or more PQRS-eligible professionals (EPs) that are subject to the 2016 Value Modifier, the QRUR shows how the VM will affect Medicare’s 2016 payments to physicians. VM cost and quality scores will also be provided in the QRURs for other practices even though they are not yet subject to the VM. If physicians or group practices feel an incentive payment or penalty was performed in error they must file an Informal Review by November 9, 2015.
2014 EHR and QCDR Data Issues
As reported in the September 3, 2015 Advocacy Update Issue, CMS discovered various errors with the 2014 Physician Quality Reporting System (PQRS) data submitted by vendors on behalf of EPs and group practices that reported via electronic health records (EHR) and qualified clinical data registries (QCDR). CMS has stated there will be no need for physicians or group practices to submit a PQRS Informal Review request.
Because of the errors, the EHR and some of the QCDR data is inconsistent. Due to these errors, CMS will not post PQRS performance data for the affected practices on Physician Compare. However, determination of PQRS and Meaningful Use payment will not be affected because they are based solely on whether the practice successfully reported rather than on their actual performance—simply receiving the data will allow CMS to deem a physician or group practice as successful for purposes of avoiding a payment adjustment in 2016 or for receiving a 2014 incentive.
For the value modifier, which involves calculating actual quality scores in addition to determining whether quality measures were reported, CMS has acknowledged the vendor data errors may create problems. Specifically, CMS will not be able to accurately calculate the PQRS portion of the Quality Composite Score. Instead, the quality score will be based solely on the claims-based outcomes measures and the Consumer Assessment of Healthcare Providers and Systems Survey, if applicable.
2014 PQRS Data Submission Problems
The AMA is aware of instances in 2014 where physicians and practices mistakenly registered for the PQRS group practice reporting option (GPRO) submission mechanism and/or at the last minute their EHR vendor would not support their preferred submission mechanism. These groups or individuals, will have to file an Informal Review by November 9, 2015. We have been told this only affects a very small percentage of EPs and practices.
How to Access the Reports and File an Informal Review
In order to access the portal to review reports and/or file an Informal Review, an EIDM account is required. CMS transitioned the portal from the Individual Access to CMS Computer Services (IACS) to the Enterprise Identity Management System (EIDM) on July 13, 2015. The IACS system is now retired, but current PQRS and VM IACS users, their data, and roles have moved to EIDM, which is accessible from the portion of the CMS Enterprise Portal at http://portal.cms.gov. The EIDM system provides a way for business partners to apply for, obtain approval for, and receive a single user ID for accessing multiple CMS applications.
For more information on 2014 feedback reports and how to request them, see: How to Obtain a QRUR.
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.
DrFirst and MSSNY have partnered to bring MSSNY members the industry’s leading e-prescribing solution at a special discounted price and information on this program can be found here: http://www.drfirst.com/mssny/mssny-lp
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.
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. OH 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 to March 27, 2016.
Information regarding e-prescribing may be accessed at the following links:
Alzheimer’s Disease & Advance Directives Webinar to Be Held On September 17
The Albany School of Public Health will hold a free education webinar on Alzheimer’s Disease & Advance Directives: A Primer for Primary Care Physicians on Thursday, September 17th from 9-10 a.m.
Learning objectives are: 1) Discuss the dramatic impact that the growing number of new Alzheimer’s patients has on both patients and caregivers 2) Describe healthcare providers’ professional obligation within their window of opportunity to have and document conversations with patients with remaining capacity about advance directives and 3) Identify the criteria for determining capacity. The program will be conducted by Wayne Shelton, PhD, MSW, Professor of Medicine and Bioethics, Alden March Bioethics Institute, Albany Medical College and Kevin Costello, MD, Assistant Professor of Medicine and
Attending, Department of Medicine, Albany Medical College. The program will provide critical information and tools to prepare physicians and healthcare providers to have constructive conversations with patients that have remaining capacity about their preferences for medical care in the advance stage of disease. Continuing medical education credits are available. To register go to: www.phlive.org
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