December 4, 2015 – Are Your Health Republic Checks Bouncing?

 Dr. Joseph R. Maldonado
December 4, 2015
Volume 15, Number 45

Dear Colleagues:

As was reported in several media outlets this week, including Crains’ Health Pulse, Politico New York and WNYC, MSSNY has heard from many physicians outraged regarding the decision of EmblemHealth to drop hundreds of physicians from its network reportedly as part of its efforts to increase the use of value-based payments. However, at first glance, it appears that many of the recipients of these non-renewal letters were physicians in smaller practices who did not receive any advance notice by Emblem of its desire to migrate their payment structure to a value-based methodology.

Last week, the New York County Medical Society issued a press release warning of disruptions to long-standing patient-physician relationships, followed up by multiple MSSNY letters to the NYS Department of Financial Services (DFS) urging an investigation into how these actions by Emblem will affect its network adequacy and whether these physicians and their patients were truly given adequate notice.

We have been advised by DFS staff that they have initiated a review of Emblem’s action, and hope to have some answers to our questions next week.  Among the questions we have posed to DFS:

  • Were these 750 physicians dropped by Emblem given any advance notice of Emblem’s intention to drop them for any reasons including because they chose to deliver care to patients in a smaller practice setting?
  • Were any of these 750 physicians dropped by Emblem given the opportunity to enter into the value-based contracts espoused by Emblem to stay within Emblem’s physician network?
  • How many patients are impacted by Emblem dropping these 750 physicians from its network?  What is the total number of patient encounters with Emblem insureds that these 750 physicians provided over the last year?
  • What is the specialty of the physicians being dropped?  What are their hospital affiliations? Has DFS or DOH reviewed whether the dropping of these physicians will create shortages in any specialty or in any particular community served by Emblem?
  • How does the timing of the notice to these dropped physicians intersect with employer open enrollment periods?  For example, it was reported that the open enrollment date for New York City employees ends on October 31, just three days after patients received notice of these physicians being dropped. Were patients of these physicians given fair notice so that they could shop around for coverage for a health plan that includes their treating physicians?

Please let us know if you have been impacted by these actions.  MSSNY and county medical societies are seeking to further identify physicians who have been impacted, as well as patients who may be willing to share their stories.  With assistance from MSSNY’s General Counsel, we have drafted a template “Dear Patient” letter for impacted physicians to customize to use for their discussions with their patients.

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

Please send your comments to

MLMIC Physianns Insurance

MSSNY’S Advocacy Matters CME Series Webinar On December 8th
Jason Helgerson, NYS Medicaid Director to Discuss Delivery System Reform Incentive Payment Program (DSRIP) and the Move to Value Based Payment

Jason Helgerson, New York’s Medicaid Director, will present on the State’s Delivery System Reform Incentive Program (DSRIP) and on the move to value based payment on MSSNY’s December 8th Advocacy Matters program. The program will run from 12:30- 1:30PM.

DSRIP´s purpose is to fundamentally restructure the health care delivery system by reinvesting in the Medicaid program, with the primary goal of reducing avoidable hospital use by 25% over 5 years. Up to $6.42 billion dollars are allocated to this program with payouts based upon achieving predefined results in system transformation, clinical management and population health.

To read our flyer, please click here.

Calling All Doctors Who Have Been Terminated by Emblem
MSSNY is trying to collect data on the physicians who have been terminated by Emblem health. We cannot help you if we do not who you are. We are in constant contact with The Department of Financial Services in an effort to assist New York State physicians who have received these notices from Emblem.

Please email our VP of Socio-Medical Economics Division Regina McNally at with your name and contact information. 

Banks Returning Health Republic Checks Due to Insufficient Funds
As you know by now, Health Republic (HR), the NYS Co-Op, closed on November 30, 2015.  MSSNY has received notices from several physicians that reimbursement checks issued by HR have been returned by the bank for insufficient funds.  We, MSSNY, would like to know how widespread this issue is.  If you have received notice from your bank that an HR check bounced, please let us know.  Please send an email to  If you can scan the check into an email that would be helpful.  If not, your email should include the date the HR check was issued, the amount of the check and whether the bank charged a fee for the transaction. Note: Please do not include patient information in your email.

On a related matter, if you have a reimbursement check from HR, it would most likely bounce if you try to deposit it.  It is urged that you send us an email indicating the number of checks, the date (s), and the amount.  We will share this information with the HR monitor.  Again, please email you for your patience while we continue to work to assist you in the process.

File by Dec. 16 to Avoid Medicare Pay Cut of 2-4 %
Practices that may have thought they were safe from Medicare payment penalties next year could be in for an unpleasant surprise if they don’t take action now.

Problems with how the Centers for Medicare & Medicaid Services (CMS) has been collecting and analyzing data related to the Physician Quality Reporting System (PQRS) and the value-based payment modifier are leading to inappropriate penalties of 2-4 percent of Medicare payments for thousands of physicians.

How to avoid the penalty: File an informal review request with CMS before midnight EST on Dec. 16. CMS has said it will verify incentive eligibility and payment adjustment determinations for practices that file such a request.

Additional information about the process and contact information for questions is available in CMS’ informal review fact sheet.

Note: CMS has said the informal review system will be down Dec. 3-7 and unable to accept requests during that time.

Register Now For Final 2015 E-Prescribing CME Webinar on Dec. 9
MSSNY will host its final 2015 free continuing medical education webinar on E-prescribing on December 9 at 7:30 a.m. for MSSNY members. Registration is now open to MSSNY physicians by clicking here.

The program, entitled, “New York State Requirement for E-prescribing of All Substances,” includes the following educational objectives:

  • Describe the e-prescribing mandate, to whom it applies, when it becomes effective, and how physicians can comply with its requirements.
  • Describe the practitioner electronic prescribing of controlled substances registration process, to whom it pertains, and the information required to be provided by physicians in order to register eRX software with the Bureau of Narcotics Enforcement.
  •  Describe the exceptions to the e-prescribing mandate and any additional requirements associated with those exceptions.
  • Describe the application process and criteria for a waiver from the e-prescribing mandate.
  • Describe what rules pertain to physicians who only prescribe non-controlled substances

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.

Further information can be obtained by contacting Terri Holmes at

E-prescribing of all substances will be required in New York State by March 27, 2016.   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.  

US Senate Passes Controversial Bill to Revise ACA and Defund Planned Parenthood
By a 52-47 vote, the United States Senate passed legislation (HR 3762) on Thursday that would repeal significant components of the Affordable Care Act.  Specifically, the bill would repeal the taxes on medical devices and the so-called “Cadillac” tax on comprehensive health insurance policies (slated to go into effect in 2018).  It would also reduce funding for the Public Health and Prevention fund created under the ACA and repeal the expansion of Medicaid contained in the ACA.  Furthermore, it would set at $0 the fines for individuals who fail to purchase health insurance coverage and large employers who fail to provide coverage to their employees, essentially repealing these mandates.  Of greatest controversy, the legislation would also defund Planned Parenthood for one year.

While the bill is expected to be passed by the House of Representatives, it is almost certainly going to be vetoed by President Obama, and there are insufficient votes for an override.    The significance, however, is that it is likely to be the first time a bill repealing large sections of the ACA has been approved by the entire Congress.  New York’s Senators Charles Schumer and Kirsten Gillibrand voted against the bill.

Revitalizing MSSNY’s Organized Medical Staff Section – Get Involved!
MSSNY members are invited to get involved in the reestablishment of our OMSS. OMSS is a viable entity to advance the interests of your medical staff, your group practice or your institution, and to air and have MSSNY help address your issues.

OMSS also offers a prime opportunity for leadership development.

We would like to invite you to participate in an online meeting at which candidates for office will introduce themselves, and elections will be held. A slate of previously nominated candidates will be presented, and nominations will be accepted from the floor. Even if you are not running for office, please join to have your vote counted. The webinar (telephone only option also available) will take place on Saturday, December 12, 2015 at 8:00 am and should last no more than two hours.

Kindly email at your earliest convenience to let us know if you will be participating.

Opportunity for Physician Peer Reviewers
The Empire State Medical, Scientific and Educational Foundation, Inc. (ESMSEF) would like to invite you to participate in physician peer review with our organization.  We have a need for physician reviewers who are board certified and in active practice.  We have an urgent need for physicians in all specialties.

ESMSEF is a subsidiary of the Medical Society of the State of New York (MSSNY) and has been performing independent medical peer review since 1984.  The Foundation currently has several contracts in New York State to perform medical peer review services.  The reviews to be performed are retrospective in nature and are time sensitive.  We generally allow approximately 10 days for completion of the physician review.  Reviews may be sent to your home or office or may be performed in our offices in either Westbury or Camillus (Syracuse).  Issues to be reviewed include medical necessity, diagnosis assignment and/or quality of care issues.

If you are interested in participating in peer review, please contact Jane Steinman, Physician Reviewer Coordinator at 1-800-437-2234 or via email at to request an application. Or, you may download our application from the “Careers” section of the Foundation website at

MSSNY Announces 2016 Medical Matters Schedule for 2016
MSSNY will begin its 2016 Medical Matters webinars on January 20, 2016 with a program entitled “Immunizations During a Disaster,” with Dr. William Valenti as faculty.  All programs will begin at 7:30am.

Registration is now open to physicians and other public health officials:

  • Go to training session and upcoming sessions tab

Educational objectives for the January 20 program are:

  • Review recommendations for immunizations during disasters
  • Review recommendations for immunizations for responders
  • Describe best practices to avoid vaccine preventable diseases (VPD) during disasters
  • Describe the importance of herd immunity

Additional program include: Public Health Preparedness 101 on February 17, 2016 and Radiological Emergencies on March 16, 2016.

Further information on these programs can be found here

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. 

Further information or assistance in registering for any of these programs, may be obtained by contact Melissa Hoffman at

Senate Finance Report on Solvadi Pricing: Profits over People
Gilead Sciences prioritized maximizing its revenue over recouping research and development costs and ensuring patient access when pricing its breakthrough hepatitis C treatment, Sovaldi, according to a Senate Finance Committee report released yesterday.

“Gilead pursued a calculated scheme for pricing and marketing its Hepatitis C drug based on one primary goal, maximizing revenue, regardless of the human consequences. There was no concrete evidence in emails, meeting minutes or presentations that basic financial matters such as R&D costs or the multi-billion dollar acquisition of Pharmasset, the drug’s first developer, factored into how Gilead set the price. Gilead knew these prices would put treatment out of the reach of millions and cause extraordinary problems for Medicare and Medicaid, but still the company went ahead,” stated the report. The drug costs $1,000 per pill or $84,000 per patient for a 12-week course of treatment. According to the report, fewer than 3% of eligible Medicaid beneficiaries received the treatment last year because of the drug’s high price. Gilead says it disagrees with the report’s findings, noting that it provides financial assistance for the treatment to uninsured individuals. (Wall Street Journal 12/1)

Mandatory Electronic Prescribing in New York State
Effective March 27, 2016, electronic prescribing for both controlled and non-controlled substances will be required in New York State.

In order to process electronic prescriptions for controlled substances (EPCS), a prescriber must select and use a certified electronic prescribing computer application that meets all federal requirements. Each unique certified computer application used to electronically prescribe controlled substances must first be registered by the practitioner with the New York State Department of Health, Bureau of Narcotic Enforcement (BNE).

Prescribers who have certified EPCS software and have completed the registration process are highly encouraged to begin electronically prescribing instead of using paper. This will allow for time to resolve technical or workflow issues prior to the mandate’s effective date.

Please be aware that implementation timelines for EPCS software vary and may be lengthy. If you have not already begun this process, it is recommended that you begin immediately.

The laws regarding issuing and dispensing prescriptions for controlled substances, from paper to the electronic method, have not changed. Only the format has changed.

Useful information related to electronic prescribing, including frequently asked questions and information regarding the EPCS registration process, can be found on BNE’s website here.

ACEP: Under New Reg, Plans Not Required To Pay Fairly for Emergency Care
A new regulation issued by the Department of the Treasury, the Department of Labor and the Department of Health and Human Services last week stated that health insurance companies can pay doctors in emergency departments essentially whatever they like, opening the door to the possibility of reimbursements that do not even cover the costs of care.  The American College of Emergency Physicians (ACEP) expressed astonishment at the ruling, given the feedback emergency physicians have given to CMS over several years, as well as the timing.  Dr. Jay Kaplan, president of ACEP, said that the organization was considering legal action.

“This new ruling will significantly benefit health insurance companies at the expense of physicians, because they know hospital emergency departments have a federal mandate to care for everyone, regardless of ability to pay,” said Dr. Jay Kaplan.  “They will continue to shift costs onto patients and medical providers, as well as shrink the number of doctors available in plans.  Instead of requiring health plans to pay fairly, this ruling guarantees that insurance companies can pay whatever they want for emergency care.  If history tells us anything it’s that insurance companies prefer to pay as close to nothing as possible, while building their war chest for profits and litigation.”

“This is a scary environment for patients,” said Dr. Kaplan.  “Insurance companies are alleging that doctors are charging too much, rather than admitting they are paying too little.  This ruling by CMS unfortunately suggests that the federal government is on the side of Big Insurance rather than patients and their physicians.”


Office Space–Sutton Place
Newly renovated medical office. Windows in every room look out to a park like setting on the plaza level. 2-4 exam rooms/offices available, possible procedure room or gym. Separate reception and waiting area, use of 3 bathrooms and a shower.  Central air and wireless. All specialties welcome. Public transportation nearby. Please call 212-772-6011 or email:

Modern 3000 sq. ft. medical office to rent near the United Nations.
Handicapped accessible; private reception area; secretarial area available; 6 exam rooms.  Ideal for ophthalmologist/optometrist. Could suit other specialties. Available for full or part time. $1300 per month for one day per week. Please contact Dr. Weissman at or call 914-772-5581.

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 /

Midtown Office- Rockefeller Center
Sunny, upscale office. Furnished or unfurnished. Tranquil Ambience, waterfall, well maintained building. MUST BE SEEN. If interested in renting please call 646-242-4742