November 6, 2015 – NY Is Not Part of the Herd

 Dr. Joseph R. Maldonado
November 6, 2015
Volume 15, Number 42

Dear Colleagues:

Standing Up for Your Beliefs and Position

Our state medical society has a long history of leading change in many controversial areas, often being the lone voice of advocacy or opposition.  History has proven that those well-reasoned and critically analyzed positions have been spot on in their assessments and recommendations.  During the tenure of the previous two presidents, MSSNY took such positions, specifically on the SGR—when were the only state that did not sign onto the national letter.  Once again, our society has risen to lead by example.

This past week, I declined to sign onto a national letter asking for particular changes in the National Association of Insurance Commissioners’ Model Bill for network adequacy. Instead, we chose to draft our own letter highlighting the merits of the more robust network adequacy legislation accomplished in New York’s legislation wrought in part through the efforts of our Immediate Past President Dr. Andrew Kleinman.  Numerous attorney generals and legislators in other states have been looking at New York’s legislation as being more protective of patient needs in access to care via network adequacy.  In addition, our state’s legislation has protected both patients and physicians when these medical services have been sought out of network.  Other state medical societies have been looking at our efforts in this arena and are opting to follow our lead in this arena.

As New Yorkers, we have always understood the challenges that prompt us to go beyond conventional participation in advocacy efforts.  We are prepared to be contrarians when solutions proffered by others shortchange our patients and profession.  We are proud of the legislation on surprise bills and network adequacy that protects New York’s patients and physicians even when our lone voice of advocacy engenders bogus claims of “limited networks that are robust” or are alluded to as purveyors of conspiracy theories.

What gives us the fortitude to be the lone person advocating for the best interests of our patients and doctors?  It is our commitment to the oaths we made to protect our patients and profession when we first entered the profession.

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

Please send your comments to

MLMIC Physianns Insurance

Council Notes
At the meeting on November 5, Council approved the following:

  • Childhood Vaccination Resolution
    MSSNY will support the repeal to eliminate all non-medical exemptions for childhood vaccinations prior to attending school in New York State.
  • Resolution 113:
    Resolution 113 was amended and adopted as follows: That the Medical Society of the State of New York investigate logistics of including MSSNY and County Medical Society opt-out dues in the NYS Department of Education biennial registration billing and payment.
  • Resolution 60:
    Council adopted substitute resolution 60, which states that MSSNY will work with the NY chapters of the American Academy of Pediatrics to advocate for the following: that health insurers comply with the law that required them to provide coverage for autism and related services; insurers take the necessary steps to include sufficient physicians in networks; work with AMA and other societies to advocate for federal legislation to require self-insured plans to provide such coverage; work with similarly interested organizations to identify gaps in services and treatment.
  • Resolution 117:
    MSSNY will seek legislation and regulation that vertically integrated hospital systems must prove to the DOH a need to employ an individual physician in the market place and obtain a Certificate of Need for each of their employed physicians and that the certificate of need process include an evaluation of the employment agreement, insofar as it be limited to fair market values of physician services and not include ancillary services.
  • Presidential Appointments to the Council Workgroup
    The workgroup will develop guidelines for collaborating with non-MSSNY physician groups seeking MSSNY engagement.
  • Presidential Nomination to AMA Senior Physicians Section
    Dan Koretz, MD will serve as the Senior Physician Section liaison with the AMA.  Dr. Koretz will provide two-way communication between MSSNY and the SPS through participation in virtual Assembly calls and the annual and interim meetings.
  • Virtual Council Meeting in January
    The January Council meeting will be held remotely, with various locations around the state connecting via WebEx.

NY Practices Waiting To See Impact Of New ICD-10 Coding System
POLITICO New York (11/3, Velasquez) reports healthcare providers in New York State “say it’s still too early to know what sort of repercussions the new [coding] system will have on their operations,” one month into the transition. As of October 1, those providers who are “covered by the Health Insurance Portability Accountability Act (HIPPA) had to transition to a tenth version of the International Statistical Classification of Diseases, also known as ICD-10.” Regina McNally, the vice president of socio-medical economics at the Medical Society of the State of New York, says, “If there are going to be some problems of any significance, we have to wait a little further down the road before those issues.”

Medical Journal Article Concludes that Higher Spending Physicians Sued Less; Profound Implications for Value-Based Payments
As was widely reported in the Washington Post  and the New York Times this week, a British Medical Journal article concluded that physicians who spent the most health-care resources on hospitalized patients had the lowest likelihood of being sued.   MSSNY will be sharing these articles with key legislators and Cuomo Administration officials, noting that the results of this study have profound consequences for efforts to shift commercial and Medicaid payments to a value-based construct.  Physicians could find themselves in a “Catch 22” situation, where in acting to assure their patients are able to get all the care they need and to reduce the risk of being sued, they may find themselves being penalized by public payors and commercial insurance companies for exceeding spending targets used under such value-based payment paradigms.

In the study, researchers tracked more than 24,000 Florida physicians over a nine-year period and found that in six specialties, physicians who were found to have spent the most health-care resources on hospitalized patients had the lowest likelihood of being sued.

MSSNY Joins AMA and Other Medical Societies in Seeking Congressional Intervention to Delay Unworkable Meaningful Use Requirements
As new CMS regulations will make Stage 3 of the electronic health record (EHR) meaningful use program even less achievable and more disruptive, MSSNY joined 110 other medical associations in a joint letter initiated by the AMA to members of the Senate  and the House urging Congress to intervene.  The letters point out that “the Centers for Medicare & Medicaid Services (CMS) has continued to layer requirement on top of requirement, usually without any real understanding of the way health care is delivered at the exam room level.”

MSSNY Board of Trustees member and Saratoga Springs ENT Dr. Robert Hughes and MSSNY staff recently joined physician leaders from other states in Washington DC to advocate for numerous bills including legislation (HR 3309, Ellmers) to reduce the hassles associated with complying with onerous federal regulations governing the use of electronic medical records.  The bill contains a provision to postpone the implementation of Meaningful Use Stage 3 until 75% of physicians can meet Meaningful Use Stage 2.

Physicians are encouraged to email their members of Congress and tell them that the nation’s patients and physicians need significant changes to meaningful use Stage 3. They also can submit comments on the Stage 3 regulations during the 60-day comment period that ends Dec. 15. The AMA’s dedicated website makes it simple to submit comments directly to Congress and CMS.

Final 2016 Medicare Physician Fee Schedule rule issued
Late last Friday, the Centers for Medicare & Medicaid Services (CMS) released the final Medicare Physician Fee Schedule rule for 2016, along with a fact sheet describing many of its most notable provisions.

The AMA notes that as a result of the interplay between numerous statutory provisions, the Medicare fee schedule conversion factor will be reduced by 0.29% in 2016, from $35.93 to $35.83.

Here’s why: The Medicare Access and Chip Reauthorization Act (MACRA), which repealed the SGR, increased the conversion factor by 0.5% on July 1 and called for additional annual updates of 0.5% from 2016 through 2019.  However, the Protecting Access to Medicare Act of 2014 enacted in April 2014, established an annual target for reductions in Medicare payment schedule expenditures that result from adjustments to misvalued codes.  The Achieving a Better Life Experience Act of 2014, enacted in December 2014, accelerated the application of the expenditure reduction target, setting targets of 1% for 2016 and 0.5% for 2017 and 2018.  Unfortunately, the Medicare payment rule only identified “misvalued code” changes that achieved 0.23% in net reductions, which required CMS to impose a 0.77% reduction to all Medicare professional services, more than offsetting the increases contained in MACRA.

Among its numerous provisions, the Medicare fee schedule rule for 2016 includes provisions to establish payments for advanced care planning.  It also sets forth terms for the bonus and penalties physicians will face in the Value-Based Modifier Program in 2018 based upon 2016 performance.  Groups of physicians with 10 or more face a bonus or penalty of +/- 4%; while solo practitioners and or physicians in groups of 9 or less face a bonus or penalty of +/- 2%.  The program will sunset after 2019 as part of the transition to the Merit Based Incentive Payment System (MIPS).

More Leeway in Two-Midnight Rule
CMS issued changes to the two-midnight rule last week that give physicians broader leeway to determine if someone should be treated on an inpatient basis. But the controversial policy is largely intact. Whether a hospital will be reimbursed for an inpatient stay that lasts fewer than two nights will depend on such factors as the severity of a patient’s symptoms and the likelihood of an adverse event. Inpatient stays that do not keep a patient in the hospital overnight will be prioritized for review. “We will continue to monitor hospital admission practices and look for any evidence of gaming,” CMS told Modern Healthcare. But instead of sending recovery audit contractors who are paid to dispute claims to conduct the initial review, quality improvement organizations will be the first to investigate. GNYHA was among the plaintiffs in a class-action suit filed earlier this year that challenged reimbursement cuts made in association with the two-midnight rule. The group voiced support for the changes in a memo released on October 30.

MSSNY’S Advocacy Matters CME Series on November 10: Foster Gesten, MD to Focus on State Health Innovation Plan (SHIP)
Foster Gesten, MD, Medical Director for the Office of Health Insurance Programs for the Department of Health will present on the State’s Health Innovation Plan on MSSNY’s November 10th  Advocacy Matters program. The program will run from 12:30- 1:30PM.   

The Centers for Medicare and Medicaid Services’ State Innovation Models Initiative is providing support to states for the development and testing of state-based models for multi-payer payment and health care delivery system transformation with the aim of improving health system performance for residents of participating states. New York State has received a grant to pursue the implementation of its Health Innovation Plan, centered on statewide implementation of an Advanced Primary Care (APC) model, which will facilitate integrated care delivery and which will rely on emerging health information technologies and primary care workforce to promote the objectives of population health. For more information on the State’s Health Innovation Plan, please click here.

The objectives of November 10th Advocacy Matters  program are as follows:

1. Describe the fundamental components of the State Health Innovation Initiative and its core objectives.

  1. Describe the Advanced Primary Care (APC) model and how physician practices can achieve this status.
  2. Describe the five strategic pillars and three enablers of system transformation.
  3. Describe how the Plan will promote meaningful, value-based payment arrangements across the State’s payers and insurers and how physician practices will be affected.

Physicians interested in participating in the coming November 10th program may register for Advocacy Matters. Please go to and click on the “Upcoming” tab.  A “Register” link appears to the right of the program name.

To read the flyer, please click here.

The Medical Society of the State of New York designates this live activity for a maximum of 1.0 AMA PRA Category 1 CreditsTM.  Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Advocacy Matters is a CME series held on the second Tuesday of every month. It is sponsored by MSSNY’s Legislative and Physician Advocacy Committee. It is intended to enhance communication with physicians concerning issues of the moment.  Elected officials, agency officials, and key legislative/agency staff will be invited to discuss regulatory and legislative matters.

Accreditation Statement: 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.

Disclosure Statement: The Medical Society of The State of New York relies upon planners and faculty participants in its CME activities to provide educational information that is objective and free of bias. In this spirit and in accordance with the guidelines of MSSNY and the ACCME, all speakers and planners for CME activities must disclose any relevant financial relationships with commercial interests whose products, devices or services may be discussed in the content of a CME activity, that might be perceived as a real or apparent conflict of interest. Any discussion of investigational or unlabeled uses of a product will be identified.

The planners and faculty participants do not have any financial arrangements or affiliations with any commercial entities whose products, research or services may be discussed in these materials.

Avoid Medicare Penalties
Reporting PQRS has never been more important. The penalty for not reporting is, at a minimum, – 2.0% but it could be more. Understanding the rules can be confusing but is necessary. MSSNY has arranged special rates for members from Covisint – a service to help practices with PQRS reporting.  With Covisint PQRS you can confidently avoid the 2017 payment adjustment of -2.0%.

Covisint features include:

  • Paper and electronic data collection methods
  • Web-based application access and data entry
  • Easy and Quick …
    The measures group option only requires 20 patients

HIPAA-compliant database

Automated data submission

MSSNY Members save $100. Call (516) 488-6100, Extension 403 or email: for your MSSNY Member discount code. Use it at the time of submission and receive a discounted submission rate of $199.

Have questions about PQRS? Plan to attend one of our live Q&A sessions to get all of your questions answered and more. Thursday, November 19, 2015 at 11:00 am ET – Click here to add this meeting to your calendar.

Visit Covisint at: or contact them at 866.823.3958 for more 

MSSNY To Conduct E-Prescribing Webinars Monday, Nov. 9 and Monday, Dec. 9
MSSNY will host two free continuing medical education webinars on E-prescribing for MSSNY members on Monday, November 9th and Wednesday, December 9, 2015 at 7:30 a.m.

Registration is now open to MSSNY physicians by clicking here.

Select “Training Center” and the “Upcoming” tab.  Then click “Register” link to the right of desired session.

A copy of the flyer can be found here.

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

  • 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 Miriam Hardin at or 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 from March 27, 2015 to March 27, 2016.  

Buyer Beware: Too Good to Be True?
There are now over 40 insurers competing for medical liability insurance in NYS. Sometimes premium quotes can seem too good to be true.  This might be because insurers are providing less coverage, shifting coverage from occurrence to claims made, or offering an attractive discount that may not persist.  If a quote seems too good to be true, give MLMIC a call at (716) 648-5923. We’ve seen a lot in our 40 years in NYS and can often spot differences that may make a difference. 

MEDCO Offering Free Crosswalk Guides
FREE Crosswalk Guides (18 Specialties) are available

Do You Want to Present Your Project at MSSNY’s 11th Annual Symposium on April 15?
MSSNY is pleased to announce our 11th Resident/Fellow/Medical Student Poster Symposium on Friday, April 15, 2016 at the Westchester Marriott in Tarrytown, New York from 2 pm – 4:30 pm. Click here for detailed guidelines.Deadline for abstract submission is 4 pm, Monday, January 25, 2016.We welcome the participation of your residents and fellows. Participants must be MSSNY members, and membership is free for first-time resident members.
Join online at

Be There! Fall Residents,YPS and Students Get Together in NYC Next Friday
Anuradha Khilnani, MD and the New York County Medical Society, in collaboration with the AMA, is hosting a networking social for physicians, residents and medical students.

When:   Friday, November 13

When:   7-9 pm

Where: The Royalton Hotel 44 W. 44th St

For Your Patients: Q&A for Health Republic Members

Q. I was previously notified that my Health Republic coverage would end on December 31, 2015. Is this a change?

A. Yes, this is a change. Your Health Republic coverage will end one month earlier on November 30, 2015.

Q. Why is my Health Republic coverage ending sooner?

A. Based on an in-depth review by the NYS Department of Financial Services and the federal Center for Medicare and Medicaid Services (CMS), it has been determined that it is in the best interest of consumers to wind-down coverage under Health Republic on November 30, 2015 rather than at the end of the year.

Q. How do I select a new plan?

A. You can:

Log in to your Marketplace account before November 16th and visit the “Plans” tab at the top of the screen.

  • Select “Find a New Plan” at the bottom of the screen to see your health plan options.
  • Once you have chosen your plan, be sure to select “confirm and checkout” to confirm your enrollment in your new plan for December 1, 2015 coverage.
  • Or, you can call our special customer service helpline at 1-855-329-8899 and our customer service representatives will help you select a new plan or give you contact information for an in-person assistor in your area who can help you.

Q. What should I consider when I select my new plan?

A. You should consider:

  • Whether your health care providers are in the new health plan’s network.
  • Whether the prescription drugs you take are covered by the new plan.
  • The premium cost of the new plan.

To find contact information for the health plans offered on NY State of Health and links to each health plan’s provider network directory visit 1

Q. Do I have to select the same metal tier (platinum, gold, silver, bronze) as I am enrolling in Health Republic?

A. No. You can select any health plan that is available in your area and any metal tier.

Q. What happens if I don’t select a plan by November 15?

A. In order to ensure you are covered during the month of December 2015 you must pick a new plan by November 15th.

Q. Do I still have coverage for the month of November?

A. Yes. Provided that you pay any required premium for the month of November 2105, you are covered by Health Republic through November 30, 2015.

Q. What if I have already met or have paid towards my deductible in my current plan?

A. If you are enrolled in a Health Republic plan that has an annual deductible, the NYS Department of Financial Services is working to ensure that your new health plan will not charge you for the amount of deductible you already met in 2015. Keep your records. You may need to provide your new plan with evidence that you have met all or part of the 2015 deductible.

Q. Will my providers be in my new plans’ network?

A. You should ask both your providers and the plan you are considering joining about whether your providers participate with the new plan. To find contact information for your health plan and a link to the plan’s provider network directory visit at:

Q. What if I am receiving treatment when my Health Republic coverage ends on November 30, 2015 and my provider is not in the new plan’s network?

A. If you are either: a) in an ongoing course of treatment with a provider for a life-threatening or a degenerative and disabling condition or disease, or b) in the second or third trimester of a pregnancy when your new coverage becomes effective on December 1, 2015, then you may be able to continue to receive care from your provider for up to 60 days (or through pregnancy) under your new health insurance policy, even if your provider does not participate in your new health insurer’s network. To receive transitional care, your provider must agree to accept as payment your new health plan’s reimbursement for such services and to certain other conditions of providing care under the new policy. If your provider agrees, you will receive the services as if they were being provided by a participating provider. You will only pay for any applicable in-network cost sharing. You, your representative or your provider should contact your new health insurer to determine if you are eligible for transitional care. To request transitional care, call your new health plan’s customer service and let them know that you are new the plan and ask how to request transitional care. If you experience any problems with the process, you can call the NYS Department of Financial Services toll free number 1-800-332-3736 for assistance in filing this request with your health plan.

Q. What should I do if I have scheduled procedures or medical care in December 2015?

A. If you have care scheduled during the month of December 2105, you should do the following:

  • Visit the NY State of Health website, call the NY State of Health Customer Service Center at 1-855-329-8899 or visit an in-person assistor to review your plan options.
  • Ask your provider which health plans they participate with.
  • Select your health plan.
  • Call your new plan’s customer service to tell them that you have scheduled procedures or care in December 2015 and ask if you need prior-authorization.

Q. If I select a plan for December 1, 2015 will I be automatically enrolled into that plan for January 1 or do I need to make a separate plan selection for January coverage?

A. Current Health Republic enrollees will need to return to the Marketplace beginning on November 16 to select a plan with an effective date of January 1, 2016.

Q. Can assistors offer support to current Health Republic members by phone instead of only providing in-person assistance?

A. Yes. Assistors can provide support telephonically to current Health Republic enrollees in order to assist in selecting plans for December 1, 2015 and January 1, 2016.

CMS Extends Deadline for PQRS Informal Review Process

CMS is extending the 2014 Informal Review period. Individual eligible professionals (EPs), Comprehensive Primary Care (CPC) practice sites, PQRS group practices, and Accountable Care Organizations (ACOs) that believe they have been incorrectly assessed the 2016 PQRS negative payment adjustment now have until 11:59 p.m. Eastern Time on November 23, 2015 to submit an informal review requesting CMS investigate incentive eligibility and/or payment adjustment determination. This is an extension from the previous deadline of November 9, 2015.

All informal review requestors will be contacted via email of a final decision by CMS within 90 days of the original request for an informal review. All decisions will be final and there will be no further review.

All informal review requests must be submitted electronically via the Quality Reporting Communication Support Page (CSP) which will be available September 9, 2015 through November 23, 2015 at 11:59 p.m.EST.

Please see 2014 Physician Quality Reporting System (PQRS): Incentive Eligibility & 2016 Negative Payment Adjustment – Informal Review Made Simple (available on the PQRS Analysis and Payment webpage) for more information.

For additional questions regarding the informal review process, contact the QualityNet Help Desk at 1-866-288-8912 (TTY 1-877-715-6222) or Monday-Friday from 7:00 a.m. to 7:00 p.m. Central Time. To avoid security violations, do not include personal identifying information, such as Social Security Number or Taxpayer Identification Number (TIN), in e-mail inquiries to the QualityNet Help Desk.






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Established, Newly Renovated Multi-Specialty Group Practice.
Full time position; Experience Preferred; Bilingual English and Chinese; OR English and Bengali; OR English and Russian; Good Salary and Benefits; Malpractice Insurance provided.
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