October 9, 2015 – What the Health Republic Shut Down Means for Physicians
Dr. Joseph R. Maldonado
October 9, 2015
Volume 15, Number 38
Last week, the DFS announced that it would not allow Health Republic, the only health co-op in New York State, to write new policies after Dec 31, 2015. Effectively, no new individual insurance policies will be written. However, those existing small business products that expire in 2016 may be allowed to continue into 2016, depending on the company’s financial status.
What does this mean to you as a physician?
- Physicians should be aware that some consumers may not continue to pay their premiums for a product they may consider defunct. If the patient has not paid their premium, Health Republic will not pay their claims. So, you need to verify that your patient still has an active policy and you should get a hard copy of this verification to substantiate any decisions or actions that you make based on this policy.
- Physicians should consider whether they can maintain their Health Republic network enrollment for the small business products that may continue until sometime in 2016. It is unclear at this time if the company will have adequate funds to reimburse physicians for professional services they have rendered. In addition, physicians should consider the implications to their practice and to their patients if they continue to provide services for a plan that will not pay them for services rendered in good faith. Physicians should consult with their practice attorney to understand their contractual obligations and any new payment agreements they might be able to consider with regard to their Health Republic patient population.
- Physicians should also review their contracts to determine whether or not they can disenroll as a provider, thus mitigating any financial losses incurred if the insurer cannot reimburse them for services rendered. Physicians should also think about the implications of these actions to their patients and be ready to provide guidance to their patients as they begin to look at other insurance products in the market. Open enrollment for the health care exchange market starts on November 1.
- Physicians should consider the ethical and legal implications of continuing to provide services to patients with serious illnesses or require ongoing treatment or surgery for a chronic condition.
- Although it is the company’s responsibility to notify its subscribers, members, patients and all providers of health care of its imminent closure, you should review your contract regarding your personal time frames for ceasing your contractual obligations.
Read your contract and make the best decision for you and your practice.
JOSEPH R. MALDONADO Jr.
Please send your comments to firstname.lastname@example.org
CMS Releases Final Rule to Permit Greater Flexibility in Meeting Meaningful Use
The Center for Medicare and Medicaid Services (CMS) this week announced a final rule attempting to reduce the hassles physicians have experienced in attempting to demonstrate Meaningful Use of electronic medical records. According to the CMS fact sheet, the changes include:
- Reducing the number of objectives from 20 to less than 10 and providing flexibility so that providers may choose measures that are most relevant to their practices;
- Aligning certain aspects of the reporting of clinical quality measures with other CMS Medicare quality reporting programs;
- Permitting a 90 day (rather than one year) reporting period for all providers in 2015, as well as extending the 90 day reporting period to providers new to EHR incentive programs in 2016 and 2017; and
- Delaying mandatory compliance with Meaningful Use Stage 3 until 2018.
AMA President Dr. Steven Stack issued the following statement in response to the issuance of the rule:
“While the AMA is still in the process of reviewing the Meaningful Use regulations published today, we are pleased that CMS and ONC listened to the AMA and the concerns of physicians in several key areas in the modifications rule. In particular, the agency addressed the delay in issuing the modifications rule by allowing a hardship exemption for physicians who are unable to attest this year, providing needed relief for those uncertain about the 2015 program requirements. We also acknowledge that the agency is working to improve patient engagement by ensuring that patients can access portals while still providing flexibility in the measure requirements.
“The AMA continues to believe that Stage 3 requires significant changes to ensure successful participation, and improve the usability and interoperability of electronic health record systems. We urge CMS to use the additional public comment period provided for Stage 3 to further improve the program and consider changes related to the Medicare Access and CHIP Reauthorization Act, which was signed into law earlier this year. We also want to make sure that EHR vendors have the time they need to further test products for interoperability, usability, safety and security. We hope that health IT certification is nimble enough to accommodate future technology innovations and that the program is not seen as final at this time.”
Date: Wednesday, October 21, 2015 from 12:00 p.m. – 1:00 p.m. (EST)
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NYU School of Medicine Receives $20M for Department of Plastic Surgery
On October 7, NYU School of Medicine announced a $20 million gift from international businessman and philanthropist Hansjӧrg Wyss to establish a named Department of Plastic Surgery at the medical school—one of the only fully-accredited, academic plastic surgery departments in the country.
The Wyss Department of Plastic Surgery has one of the largest residency and fellowship programs in the world, as well as a research program that has made contributions in transplantation, wound healing, craniofacial biology, surgical simulation, and distraction osteogenesis. It also has the largest academic group of board-certified plastic surgeons in the country, with expertise in reconstructive facial surgery, microsurgery, breast reconstructive surgery, aesthetic surgery, wound care and hand surgery.
A native of Switzerland, Mr. Wyss served as CEO of Synthes, Inc., a medical research and device manufacturing company.
Federal Officials Permit NY AG to Investigate ERISA Health Plan Violations
New York Attorney General Eric Schneiderman and US Department of Labor officials announced this week that they would share information and work cooperatively to address violations of the federal Employee Retirement Income Security Act (ERISA) and New York State laws covering health insurance plans. The agreement makes it possible for the two law enforcement agencies to refer cases to one another, conduct joint investigations into potential violations of law and assist each other with enforcement cases. To read the joint press release, click here.
Currently, New York State is prohibited from enforcing New York laws against self-insured health plans, which provide health insurance coverage for about half of New York workers. As such, the many physician and patient protections MSSNY together with other groups have successfully fought to achieve in New York do not apply to these self-insured plans According to the press release, the agreement will allow the NY AG and DOL to collaborate on enforcement efforts involving New York insurance companies violating state and federal law. These carriers often use the same procedures to administer self-insured health plans on behalf of employers.
Attorney General Schneidermansaid “New Yorkers work hard for the wages they are paid and the employee benefits they are promised – and my office will do its part to ensure that workers are not cheated out of the benefits they have earned. By teaming up with the U.S. Department of Labor’s Employee Benefits Security Administration, we will make sure that all types of health plans comply with our vital federal and state consumer protection laws, such as the federal Affordable Care Act’s preventive services provisions and laws requiring equal coverage for mental health and addiction treatment.”
The press release also notes that consumers with questions or concerns about health care matters should call the Attorney General’s Health Care Bureau Helpline at 1-800-428-9071.
CMS Virtual Office Hours Series Regarding 2015 PQRS
The series will include three separate sessions that will cover topics related to PQRS measures, such as explaining what a quality measures is, measures-related resources and next steps for participation in 2015 PQRS.
The first session, titled “2015 PQRS Reporting: Introduction to Quality Measure Reporting”, has been scheduled for Wednesday, October 14, 2015 from 2:00 – 3:00 p.m. ET. Dates and times for other sessions in the series will be announced soon.
This PQRS Virtual Office Hours session will allow stakeholders an opportunity to ask a CMS representative questions about how to get started with quality measures for 2015 PQRS reporting. To participate in this session, please register beginning on Wednesday, October 7th 2015 at 12:00 p.m. ET here.
A few notes about this webinar:
- You will only be able to register on or after 12:00 p.m. EST on October 7th, 2015. If you attempt to register before this time you will receive an error message
- Only a limited number of participants will be allowed to register.
- Only quality measures questions for 2015 PQRS reporting will be addressed on this call. All other questions, including questions regarding program requirements and/or policy, should be directed to the QualityNet help desk.
Want more information about PQRS?
Complete information about PQRS is available on the CMS PQRS web site.
EpiPens Save Lives But Can Cause Injury, Too
A new case series published online on October 6 in Annals of Emergency Medicine identifies design features of EpiPens, the most commonly used autoinjector, that appear to be contributing to injuries in children (“Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children”).
“We were surprised by the severity of some of these injuries, including thigh lacerations and embedded needles,” said lead study author Julie Brown, MDCM, MPH, of Seattle Children’s Hospital and University of Washington in Seattle, Wash. “We can’t think of anywhere else in pediatric medicine where we would hold a needle in an awake child’s leg for 10 seconds. That’s a set-up for injury, particularly in the uncontrolled, stressful setting of anaphylaxis. In addition, the instructions for use do not mention patient restraint, so parents are not appropriately prepared.”
Researchers identified 25 cases of epinephrine autoinjector-related injuries from intentional use to treat a child’s allergic reaction. (One additional case involved a 5-year-old child who accidentally injected himself in the ankle with his older cousin’s EpiPen. The needle was bent underneath the boy’s skin and had to be removed at the emergency department.) Twenty children experienced lacerations, as did one nurse. In four cases, the needle stuck in the child’s limb. The EpiPens were administered principally by the patient’s parent (15 cases, including two nurses), though some injuries were also caused by nurses (six cases) and educators (three cases). Lacerations were up to 3 inches long.
Dr. Brown and her team made five recommendations for reducing the risk of injury when using an EpiPen:
- The child’s leg should be immobilized.
- The action of administering epinephrine and site of delivery should be as well controlled as possible.
- The needle should remain inserted in the thigh for as short a time as possible.
- The needle should be strong enough that it does not bend during use.
- The needle should never be reinserted.
A recently marketed device, the Auvi-Q (Allerject in Canada) has a self-retracting needle that is gone in under two seconds. “On the face of it, this would appear to be a safer design for use in children,” commented Dr. Brown. “While EpiPen likely holds a larger share of the epinephrine auto-injector market, it is notable that we did not see any injuries associated with the use of Auvi-Q or Allerject devices, even in recent years.”
An estimated 5.9 million children in the United States have a food allergy. .
Attention Paper Claim Submitters: Changes Due to the Implementation of ICD-10
With the implementation of ICD 10 on 10/1/2015, it is important to use the appropriate ICD Indicators on claim submissions.
The “ICD Indicator” identifies the ICD code set being reported. It is imperative that you enter the applicable ICD indicator according to the following:
Dates of service 10/1/2015 and after, the ICD-10-CM indicator should be “0.”
Dates of service 9/30/2015 and prior, the ICD-9-CM indicator should be “9.”
Line item 21 on the CMS 1500 claim form or the electronic equivalent shall be submitted with the appropriate indicator of “0” for ICD-10-CM or “9” for ICD-9-CM.
Note: It is mandatory that you enter the indicator as a single digit between the vertical, dotted lines. Failure to enter the appropriate indicator will result in your claim being rejected/denied.
For additional information, visit the ICD-10-CM section of our website.
SCOTUS Will Not Hear Challenge to New York’s School Vaccination Rules
The US Supreme Court has decided not to hear a challenge to New York’s requirement that all children be vaccinated before they can attend public school, upholding the Second Circuit’s court ruling that said the policy does not violate students’ constitutional right of religious freedom. In the New York case, two students who sought religious exemptions to avoid vaccination requirements were temporarily barred from going to school after a fellow student was diagnosed with chicken pox. A judge denied the request for a vaccine exemption after finding that the mother’s concerns were primarily health-related and not based in religion.
Chronically Ill in ACA Plans Pay More Drug Costs than the Employer Covered
Chronically ill people enrolled in individual plans sold on the ACA exchanges “pay on average twice as much out-of-pocket for prescription drugs each year than people covered through their workplace,” according to a study published in the Health Affairs journal on October 5. Researchers at Emory University in Atlanta found that patients with at least one chronic condition paid on average $621 out of pocket for prescription costs on silver plans, compared to $304 for those with employer-based coverage. Overall, the study said, patients in the most-popular silver plans pay 46 percent of their total drug spending on average, compared to 20 percent for patients in typical employer-sponsored plans.
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