August 12, 2016 – Did You Know MACRA Is Mandatory?

Dr. Reid
Dr. Malcolm Reid

Aug. 12, 2016
Volume 16, Number 29


Dear Colleagues:
The alphabet soup continues.

Yesterday, MSSNY had a call with several Medicare officials regarding the government’s proposed rule about MACRA, MIPS and APMs. Surprisingly, they were interested in learning what MSSNY is hearing from our members about the potential roll out of THE new payment proposal.

We asked them what they were hearing about the potential for delay and the rumored 90-day time period of reporting quality measures for compliance with this proposal. Regrettably, all remains up in the air. We do not know if the Final Rule anticipated to be published in November will delay the anticipated effective date of January 1, 2017.

We do know is that the payment proposal is MANDATORY.

We don’t much more than that and neither do they.

We have sent out an email to specialty societies to learn if they have created or developed specialty-specific lists of measures that will coincide with the quality reporting related to the specialty and the physician’s patient population. We are waiting to hear from them.

MSSNY wants to educate our members on CMS’ payment proposal since, I repeat, it is mandatory. Yet, we are in a hurry-up-and-wait mode. We will give you as much information as we can as soon as we are able.

However, since this is a top down operation, we can’t force them to help us to help you.

Stay tuned.

Malcolm Reid, MD, MPP
MSSNY President

Please send your comments to

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Applications for Primary Care Model (CPC) Now Open
On August 1, CMS opened the application period for practices to participate in the new primary care model, Comprehensive Primary Care Plus (CPC+, which is available to practices in Region II, NY & NJ.  CPC+ is a five-year primary care medical home model beginning January 2017 that will operate in 14 regions across the U.S.

The goal of the model is to give primary care practices more flexibility in caring for their patients in the way they think will deliver the best outcomes and to pay them for achieving results and improving care. CPC+ is an opportunity for practices of diverse sizes, structures, and ownership types who are interested in qualifying for the incentive payment for Advanced Alternative Payment Models through the proposed CMS Quality Payment Program. CMS estimates that up to 5,000 primary care practices serving an estimated 3.5 million Medicare beneficiaries could participate in the model.

Additionally, other payers, including commercial insurers and state Medicaid agencies, are partnering with CMS to provide enhanced support to the primary care practices selected to participate in CPC+.  The practice application period runs from August 1 – September 15, 2016.

More information is available on the CPC+ website.

Other materials your members might be interested in:

General questions about CPC+ can be submitted to

DFS to Hold September 8 Hearing to Examine Anthem-Cigna Merger Proposal
New York’s Department of Financial Services will hold a hearing in New York City on September 8 to obtain public input regarding the proposal of Anthem (the parent of Empire) to acquire health insurance giant Cigna.

MSSNY’s President Dr. Malcolm Reid is planning to testify at this hearing to express MSSNY’s great concern with the continuing consolidation of the health insurance industry, and its adverse impact on patient care.  Interested physicians are also invited to testify by submitting a request to with the heading “ANTHEM-CIGNA 2016 HEARING”.  To read the full hearing notice, click here.

Last week, DFS Superintendent Maria Vullo public released a letter ( noting that DFS has “serious concerns that Anthem’s proposed acquisition of Cigna will adversely impact the competitiveness of the health insurance market and harm consumers in New York”.

This action followed the filing of litigation by the US Department of Justice (See the press release here to block the proposed Anthem takeover of Cigna, as well as the proposed Aetna takeover of Humana.  In announcing the suit, DOJ noted that the proposed mergers of four of the five largest health insurance companies in the country “are unprecedented in their scale and in their scope”.

The DOJ intervention had been strongly supported by the American Medical Association, numerous state medical societies across the country including MSSNY, and several powerful consumer/patient advocacy groups.

The letter from Superintendent Vullo noted the huge market impact if Anthem and Cigna were permitted to merge.  It would increase Anthem’s market share across commercial products to 31.2% statewide, of which Anthem would command 9.8% of New York’s fully insured market and 47.6% of the self-insured market.  The biggest impact would be felt in the New York City metro area, where Anthem would control nearly 70% percent of the commercial self-insured market in the Bronx and Staten Island, 63% in Queens and Brooklyn, and 55% in Putnam County.

“Increased concentration means that insurers are more able to offer non-negotiable rates to providers in a take it or leave it deal. Therefore, the merger likely would limit New Yorkers’ access to healthcare because providers would be forced either to not participate with the dominant insurer or to cut hours or services in order to accommodate a deal they have to accept. This result would be highly problematic for New York consumers.” stated Superintendent Vullo in the letter.

New York Health Insurance Exchange Releases Enrollment Report
The New York State of Health release a report today that show that enrollment through New York’s Health Insurance Exchange increased by 33%, or nearly 700,000 enrollees from the previous enrollment period, and that 92% of those enrolled through the Exchange report that they did not have health insurance at the time they applied.

The full report from NYSOH is available here.

A fact sheet summarizing the demographic data is available here.

According to the report, as of January 31, 2016, 2,833,823 New Yorkers enrolled in coverage through the NY State of Health’s Individual Marketplace. This includes 271,964 people enrolled in Qualified Health Plans (QHP), 379,559 people enrolled in the Essential Plan (EP), 1,966,920 people enrolled in Medicaid, and 215,380 enrolled in Child Health Plus (CHP).

With regard to individual QHPs, Fidelis (26%) garnered the largest market share, followed by Empire, Oscar, Metro Plus and Health First all with 10% market share. As of January 31, 2016, 16% of the enrollees are enrolled in Platinum plans, 14% are in Gold plans, 25% are in Silver plans without cost sharing reductions, 17 % are in a Silver costsharing reduction plan, 26 % are in Bronze plans, and 2 percent are in Catastrophic plans.

CDC: Infants with Neonatal Abstinence Syndrome up 300% in 15 Years
The number of babies being born in the United States addicted to opioids (NAS) has tripled in a 15-year stretch, according” to a CDC report published Aug. 12 in the Morbidity and Mortality Weekly Report. The CDC “said…that the findings, based on hospital data, are likely underestimates of the true problem and point to an urgent need for public health efforts to help pregnant women deal with addiction.” The report revealed that “the incidence of neonatal abstinence syndrome jumped to 6 per 1,000 hospital births in 2013, up from 1.5 per 1,000 in 1999. Maine, Vermont and West Virginia – recorded more than 30 such cases per every 1,000 births by 2013.” New York recorded 3.6 per 1,000 (2013), up from 2.8 (2012); 2.6 in 2011; and 1.9 in 2010.

NYC Medical Schools Will Stop Using Unclaimed Bodies as Cadavers
The NY Times (8/10)  reports “eight medical schools in New York City will no longer accept the city’s unclaimed bodies as cadavers,” the schools announced on Wednesday. Additionally, “a group representing the 16 medical schools in the state is withdrawing its opposition to a recently passed bill that would end the educational use of bodies with no known survivors.”

The bill “passed both houses overwhelmingly in June, a month after a New York Times investigation highlighted provisions in the current law that give families as little as 48 hours to claim a relative’s body before the city must make it available for dissection or embalming practice.” The bill is now awaiting Gov. Andrew Cuomo’s signature.

Medicare Telehealth Services Wednesday, August 31 at 1-2 PM EST
NGS Medicare is holding a 1-hour webinar about Telehealth services.  If you are interested and have the time, click on the GREEN register box below to register for this program. During this webinar we will provide you with insight into covered Medicare telehealth services and coverage requirements. We will discuss originating sites, equipment requirements, and billing and payment guidelines.  Read More

During this webinar we will provide you with insight into covered Medicare telehealth services and coverage requirements. We will discuss originating sites, equipment requirements, and billing and payment guidelines. Read More

Notice Act Went Into Effect on August 6: Must Tell PTs re Out-of-Pocket Costs
The NY Times (8/6) the Notice Act, passed by Congress last year, went into effect on August 6. The new Medicare law “requires hospitals to notify patients that they may incur huge out-of-pocket costs if they stay more than 24 hours without being formally admitted” and the “patients can expect to start receiving the warnings in January.” According to the Times, the Administration “issued rules last week to carry out the new law,” which will let hospitals “keep Medicare patients in observation status,” and while “some of the patients will be responsible for nursing home costs,” they would still get the “time in a hospital under observation [to] count toward the three-day inpatient stay required for Medicare coverage.”

Legislation Enacted Regarding Drugs Used for Detox or Maintenance Treatment of Opioid Addiction in Medicaid Fee-for-Service (FFS) & Medicaid Managed Care
Per changes to Social Services Law section 364j, and Public Health Law section 273, prior authorization is not allowable for initial or renewal prescriptions for preferred or formulary buprenorphine or injectable naltrexone when used for detoxification or maintenance treatment of opioid addiction. Food and Drug Administration (FDA) and Compendia supported frequency, quantity and/or duration limits may continue to be applied.

To obtain preferred/formulary drug listings and plan limitations please see the following websites:

  • Medicaid FFS Preferred Drug List and Pharmacy Prior Authorization Programs-
  • Medicaid Managed Care Pharmacy Formulary and Benefit Information-

Change to Medicaid Payment of Part C Co-payment and Co-insurance Liabilities
Effective April 1, 2016, an amendment to New York State Social Services Law changes Medicaid reimbursement of Medicare Part C (Medicare Advantage or Medicare managed care) co-payment and/or co-insurance liabilities for services provided to dually eligible Medicaid members. Dually eligible members are those individuals having both Medicare and Medicaid coverage.

Presently the Medicaid program pays the full co-payment or co-insurance amounts for Medicare Part C claims. Retro-actively to April 1, 2016, Medicaid will reimburse at the rate of eighty-five percent (85%) of the Medicare Part C co-payment or co-insurance amount. The Department is in the process of making the necessary eMedNY system changes to enable the implementation of the new payment policy. Implementation will be applied retro-actively pending system support. Paid claims will then be adjusted automatically to reflect the new cost-sharing limits.

This change will affect institutional claims and professional claims when submitting claims for Medicaid reimbursement of a Medicare Part C co-payment or co-insurance. This change will also apply to Pharmacy Claims for drugs and supplies when submitted via a NCPDP transaction or as a professional claim.

There is no change to the current reimbursement methodology of Medicare Part C co-payment/co-insurance amounts for ambulance providers and psychologists. Medicaid will continue to reimburse these providers the full Medicare Part C co-payment/co-insurance amounts.

Note: A provider of a Medicare Part C benefit cannot seek to recover any co-payment, or coinsurance amount from Medicare/Medicaid dually eligible individuals. The provider is required to accept the Medicare Part C health plan payment and any Medicaid payment as payment in full for the service. The member may not be billed for any Medicare Part C co-payment/co-insurance amount that is not reimbursed by Medicaid.


Luxurious Medical Office Space to Share in Midtown (East) Manhattan! $6,950/monthly
Plastic surgeons desire to share office space (entire office is app. 5,000 square ft., Grade A building) with any medical or surgical specialty (Plastic, Facial plastic, dermatology, surgical subspecialty).  Space is located in concierge building on 3rd Avenue (3 blocks to Grand Central Station).

2-year sublease starting immediately; includes spacious doctor’s office with wall of windows (15 x 12 ft), and doctor’s staff office (9 x 8 ft).  The shared space includes luxurious waiting room (29 x 15 ½ ft) with a grand custom-made mahogany reception desk, three patient exam rooms (one used as procedure room which is 15 x 13 ft), the kitchen (10 x 8 ft), the photo room (8 x 7 ft), and staff bathroom (7 x 6 ft). Price negotiable.  Serious inquiries only, may contact us at 201-615-6963 or email us:

Brand-New Medical Office for Sale in Lynbrook. Ground Floor in Medical Office Bldg. Parking Available
Close to all area hospitals. Ideal for any specialty. Two spacious exam rooms with sinks, cabinetry and two brand-new exam tables. One consultation room, receptionist’s space, waiting area, one bathroom and lab area. Fully furnished. Asking $125,000 (negotiable). Please email to arrange for a viewing.

Office to Share/Rent
Medical Co-op Building located on East 60th Street, NYC. Includes one consult room and 2 examination rooms, waiting room, 2 bathrooms, plus 2 medical assistants. Space for one secretary. Available 2.5 days per week.  Free internet and Wi-Fi. For more information, contact or (212) 230-1144.

Want to Rent your Medical Office? Need to Lease Space to Expand your Practice?
Clineeds is an online platform designed to help physicians find or rent medical office space. Listing is completely FREE! Sign up today at We take care of the rest!

Physician Opportunities

Crown Medical PC Needs a New Internist and Pediatrician to Join Our Team! Salary $200,000 + plus benefits.
As a part of our continued growth, we are searching for a new Internist and Pediatrician to join our team. Salary is $200,000 + plus benefits.
Primary Responsibilities:
Examines, diagnoses and treats patients for acute injuries, infections, and illnesses
Counsels and educates patients and families about acute and chronic conditions or concerns
Documents items such as: chief complaint, past medical, family, and social history, review of systems, examinations, medications, allergies, assessment and plan
Formulates diagnostic and treatment plans
Prescribes and administers medications, therapies, and procedures
Orders lab and imaging tests to determine and manage an immediate treatment plan and provides advice on follow up
Responsible for the coordination of care with specialists and appropriate ancillary services
Completes all documentation and paperwork in a timely manner
Maintains quality of care standards as defined by the practice

Required Qualifications:
Active and unrestricted New York medical license
Board certified in Internal Medicine or Pediatrics
Current and unrestricted DEA certificate
Effective communication skills
Outstanding organization skills and ability to multi-task
Takes Initiative, creative, has problem solving ability, is adaptable, and flexible
Ability to work without direct supervision and practice autonomously
Ability to work in fast-paced environment
Crown Medical, PC / ER Medical, PC
Contact: Michael Furman
Practice Administrator

Nurse Practitioner/ Family Practice Physician
Full time/part time Urgent Care; Primary care/urgent care experience necessary. Rome NY. 315-335-7777