November 20, 2015 – Doctors Owed Millions by HR

 Dr. Joseph R. Maldonado
November 20, 2015
Volume 15, Number 44

Dear Colleagues:

MSSNY continues to communicate regularly with key staff at the New York Department of Financial Services (DFS), the New York State of Health, and the Governor’s office to obtain necessary information for physicians to be able to help their patients with the enrollment decisions they will have to make, as well as to assure that physicians are fully compensated for the care they have provided to patients insured by Health Republic.

This week, MSSNY’s advocacy on behalf of physicians treating Health Republic insured patients received much press attention across New York State this week after publicly releasing the results of its survey regarding the huge amounts of payments outstanding to these physicians. Of the over 850 respondents to MSSNY’s survey, 42% have outstanding claims to Health Republic, of which:

  • 9% are owed $100,000 or more
  • 19% are owed $25,000 or more
  • 47% are owed $5,000 or more

At the same time, MSSNY has heard from multiple physician practices that are owed between $1 and $5 million. Combining the survey results with financial data received from numerous physician practices across the state, it’s estimated that physicians across New York State are owed at least tens of millions of dollars from Health Republic.

Articles were printed in Crains Health Pulse, Newsday, the Syracuse Post-Standard; Buffalo Business First and the Riverhead Local.

At a time when the State is seeking to engage physicians and patients in new payment models and new networks, it is imperative that the State insure that physicians are treated fairly by insurance companies when they participate in such state-promoted products and innovation.  We are very concerned that physicians may be very reluctant to participate in what they view as risky health reform initiatives that promise upside benefits but ultimately could put their medical practices at risk.

Last week, DFS announced that Health Republic enrollees who do not select a new plan by November 30 will be auto-enrolled in Excellus, MVP or Fidelis for the remainder of 2015, provided consumers pay their premium by December 10.  In addition, Fidelis, Excellus, and MVP agreed to credit any deductible and out-of-pocket amounts that consumers have already paid through their Health Republic coverage during 2015 – helping ensure that individuals who make the transition will not be required to restart these payments in 2015.

Physicians who have not completed MSSNY’s survey yet may do so here.

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

Please send your comments to

MLMIC Physianns Insurance

Advice from Socio-Medical Economics re Closing of Health Republic (HR), Effective November 30, 2015
We are aware that there are misconceptions and confusion regarding the patient’s financial liability with this Co-Op failure. The fact that the Co-Op is closing on November 30th does not make medical care and treatment not covered when provided by an HR in-network practitioner to HR enrollees.

If an in-network HR physician is treating a HR enrollee, by contract, the physician is prohibited from billing the patient beyond any applicable deductible, coinsurance or copayment for covered services.  Billing beyond these amounts is considered “balance billing.” This balance billing prohibition is good for the term of the contract which ends on November 30, 2015.  HR and the NYS Department of Financial Services (DFS) have issued notices for patients to call a special hotline number (1-800-342-3736) with concerns about being billed beyond their cost sharing amounts. Staff from DFS indicated that they are trying to create a user-friendly system for physicians to research the patients’ 2015 deductible standing. If possible, if DFS can create a central repository for this research, it would be very helpful for physicians and their staffs.

For those physicians who have outstanding claims with Health Republic (HR) and want to be on record with regard to their debt resulting from this closure, please utilize one consumer complaint form from the following link to record the total dollar value expected from HR.  Submitting this information to DFS will not constitute any commitment from DFS or HR with respect to your recovery concerning your claims.

The HR patient is financially responsible for any unmet 2015 deductible and charges for non-covered services.  These would be the only exceptions that an HR in-network physician could bill an HR enrollee for through 11/30/15.

The New York State of Health has prepared the following Q&A to assist HR enrollees with the transition.   Some of this information should be helpful for our MSSNY members, as well:

Part of the Q&A for the patients reads as follows:

  1. What if I have already met or have paid towards my deductible in my current plan?
  2. 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.

We are in the process of asking HR, Excellus, Fidelis, and MVP if there will be a computer system for you to be able to verify a patient’s 2015 deductible status.  So far, we have been told that the specific mechanism has not yet been defined.  As soon as we are advised, we will be sure to alert you.

However, if you are scheduling a visit for a former HR enrollee for services rendered from 12/1 through 12/31/15, it is urged that you ask the patient to bring their latest HR EOB that shows their 2015 deductible standing.  If it has been met, the patient would only be liable for their co-payment or co-insurance.  If their 2015 deductible has not been met, you would be able to charge them that amount up to your contracted fee schedule with Excellus, Fidelis, or MVP.

If you have additional questions concerning this matter, please email Regina McNally, VP, Division of Socio-Medical Economics at

Survey of the Week

How is your ICD-10 Implementation Working?
Please answer this one question survey.

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

CMS Finalizes Rule for Medicare “Virtual” Bundled Payments for Lower Joint Replacement
Despite concerns expressed by many physician and hospital groups, Medicare payments for hip and knee replacements in Buffalo and New York City metropolitan areas, as well as 65 other regions across the country, will be subject to a “virtual bundling” program, according to an announcement this week from CMS.   For more information, click here, here  and here.

Under the new program, the “Comprehensive Care for Joint Replacement (CCJR)” model, acute care hospitals in certain 67 geographic areas will receive retrospective reward payments or face financial liability relating to episodes of care for lower extremity joint replacement (LEJR).  While Medicare payments to hospitals, physicians and other providers would continue to be made on a fee for service basis, the acute care hospital that is the site of surgery would be held accountable for spending during the episode of care. There is a 5 year performance period, beginning April 1, 2016, and ending December 31, 2020.

Under the program, the episode of care begins with an admission to a participant hospital of a beneficiary who is ultimately discharged under MS-DRG 469 (Major joint replacement or reattachment of lower extremity with major complications or comorbidities) or 470 (Major joint replacement or reattachment of lower extremity without major complications or comorbidities) and ends 90 days post-discharge in order to cover the complete period of recovery for beneficiaries. The episode includes all related items and services paid under Medicare Part A and Part B for all Medicare fee-for-service beneficiaries, with the exception of certain exclusions.  Depending on the hospital’s quality and cost performance during the episode, the hospital would either earn a financial reward or be required to repay Medicare for a portion of the costs.

In the first year, 2016, there would payment rewards only for the hospital, no penalties.  Starting in 2017, the financial penalties are phased in.  In 2017, the potential penalty is capped at 5%.  In 2018, the penalty would be capped at 10%, and in 2019 and 2020, the penalty is capped at 20%.

CMS notes that “a participant hospital may wish to enter into certain financial arrangements with collaborating providers and suppliers who are engaged in care redesign with the hospital and who furnish services to the beneficiary during an episode. Under these arrangements, a participant hospital may share payments received from Medicare as a result of reduced episode spending and hospital internal cost savings with collaborating providers and suppliers, subject to parameters outlined in the rule. Participant hospitals may also share financial accountability for increased episode spending with collaborating providers and suppliers.”

The 67 areas across the country encompass numerous major population centers including 800 hospitals.  The locations where this “virtual bundling” program will occur include Erie and Niagara counties in Western New York, and Bronx, Dutchess, Kings, Nassau, New York, Orange, Putnam, Queens, Richmond, Rockland, Suffolk and Westchester counties in downstate New York.

Medicare Advantage Plan to Shut Down
Touchstone Health HMO, a Medicare Advantage plan, will wind down operations at the end of the year, ending coverage for more than 10,000 members.

The White Plains insurer posted a notice on its website that informed members in New York City and Westchester and Orange counties that they would “no longer be enrolled beginning January 1, 2016.”

In October 2010, the insurer had about 17,000 members, with optimistic projections of clearing the 20,000 threshold. But membership fell 36%, to 10,864, in October 2015, according to CMS data.

Founded in 1998, the company is majority-owned by Essex Woodlands, a health care venture-capital fund, and Garden City, L.I.’s HealthCare Partners IPA. Essex Woodlands has a 60% stake—its managing director, Steve Wiggins, a founder of Oxford Health Plans, is on Touchstone’s board—with the rest held by HCP.

By the end of 2014, Touchstone was $8.5 million below its minimum net worth requirements, with assets exceeding liabilities by $9.6 million. The insurer earned $402,000 in net income on $157.9 million in revenue, with a profit margin under 1%.

A spokesman for the state Department of Financial Services said the closure “was a voluntary decision by the company. We’re working with the company and other regulators to help ensure consumers are protected.” (Crains 11/12/15)

MSSNY Announces Physician’s Emergency Preparedness Toolkit; Earn up To 15 Free CMEs
The Medical Society of the State of New York announces the creation of the Physician’s Emergency Preparedness Toolkit.  This toolkit provides resources necessary to enhance public health security and preparedness for all hazards and contains an extensive list of electronic resources for physicians to use during, or in preparation of, public health emergencies.   Upon completion of the toolkit, physicians can receive up to 15 hours of free continuing medical education credits.

The toolkit is comprised of four modules and is available at the MSSNY CME website here.   Physicians new to the MSSNY CME site will need to create a username and password.   Once registered, and logged into the site, click “My training page” on the toolbar located at the top of the instruction page.   The modules discuss liability protections for physicians during a public health emergency, provides information on the federal and state framework for responding to a public health emergency, and the best practices for a public health emergency.

The toolkit also includes:

  • A physician “go” bag checklist
  • An emergency preparedness checklist
  • A Psychological Impact desk reference card
  • A Biological, Chemical and Radiological Terrorism desk reference card

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 designated this enduring material for a maximum of 15 AMA PRA Category 1 Credits TM. Physicians should claim only the credits commensurate with the extent of their participation in the activity.

MSSNY has also created an Emergency Preparedness Podcast.  The podcast features discussions with several of New York’s preeminent experts on emergency preparedness and focuses on a remembrance of the events of September 11th, 2001 and on MSSNY’s efforts toward an aware and prepared physician and healthcare provider community in New York State.  The podcast can be accessed here.

The toolkit was created by members of the MSSNY’s Committee on Emergency Preparedness and Disaster/Terrorism Response Committee in cooperation with the New York State Department of Health.  A copy of the flyer for the toolkit and podcast is here.

For further assistance and/or questions please contact Pat Clancy at or Melissa Hoffman at

“With 44 Rx Opioid Related Deaths A Day, What Can One Physician Do?”
The Medical Society of the State of New York announces that its website has resources, tools, best practices, and voluntary education programs to help physicians to better understand the opioid epidemic.  The Medical Society is one of eight state societies that is part of the AMA’s Task Force to Reduce Opioid Abuse.   Established in 2014, this task force has embraced five concepts for implementation throughout the nation. The Task Force believes that physicians have a professional obligation to reverse the nation’s opioid epidemic. The five goals of The Task Force are:

  • Increase physicians’ registration and use of effective PMPs
  • Enhance physicians’ education on effective, evidence-based prescribing
  • Reduce the stigma of pain and promote comprehensive assessment and treatment
  • Reduce the stigma of substance use disorder and enhance access to treatment
  • Expand access to naloxone in the community and through co-prescribing

MSSNY recognizes the severity of this public health epidemic and is committed to implementing solutions to combat it.  In New York, we have already reduced the incidence of doctor shopping by 86% because physicians are checking the Prescription Monitoring Program prior to prescribing a controlled substance. MSSNY also supported legislation to increase access to naloxone to reduce deaths from overdose.  MSSNY also supports efforts increase voluntary education and training for physicians on safe prescribing practices.   According to IMS data, New York has seen substantial decreases in the number of prescriptions written for oxycodone, hydrocodone and other controlled substances. New York’s utilization rate for these medications is below other states that currently require prescriber education of opioid medications. But there’s more to do.   The MSSNY website provides information on best practices that physicians may find helpful when considering a controlled substance and common recommendations found in opioid prescribing guidelines, including tools such as opioid calculators. Additionally, there are free continuing medical education programs through the PCSS-O and prevention and other information for your patients.  To learn more, click here.

MSSNY representatives to the AMA Task Force to Reduce Opioid Abuse are MSSNY Councilor, Frank Dowling, MD and Pat Clancy, MSSNY Vice President for Public Health and Education. Further information can be obtained by contacting Pat Clancy at

Register Now For Final 2015 E-Prescribing CME Webinar on Dec. 9th
The Medical Society of the State of New York 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. Select training session and the upcoming tabs.

The webinar will be held on Wednesday, December 9, 2015 at 7:30 a.m.  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.

MSSNY Announces 2016 Medical Matters Schedule for 2016
The Medical Society of the State of New York 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

Informal Review Request Period for 2016 Value Modifier Open Now Through November 23, 2015
The period for requesting an informal review of the 2016 Value Modifier is open now and ends November 23, 2015. For groups with 10 or more eligible professionals (EPs) that are subject to the 2016 Value Modifier, CMS established an Informal Review Period to request a correction of a perceived error in their 2016 Value Modifier calculation. These groups may request an informal review of their 2016 Value Modifier determination, now through November 23, 2015 11:59pm EST.

The 2014 Annual Quality and Resource Use Reports (QRURs) are now available for every group practice and solo practitioner nationwide. Groups and solo practitioners are identified in the QRURs by their Taxpayer Identification Number (TIN). The QRURs are also available for groups and solo practitioners that participated in the Medicare Shared Savings Program, the Pioneer Accountable Care Organization (ACO) Model, or the Comprehensive Primary Care initiative in 2014, and to those TINs consisting only of non-physician EPs.

The 2014 Annual QRURs show how groups and solo practitioners performed in 2014 on the quality and cost measures used to calculate the 2016 Value Modifier. For groups with 10 or more EPs that are subject to the 2016 Value Modifier, the QRUR shows how the Value Modifier will apply to physician payments under the Medicare Physician Fee Schedule (PFS) for physicians who bill under the group’s TIN in 2016. For all other groups and solo practitioners, the QRUR is for informational purposes only and will not affect their payments under the Medicare PFS in 2016.

Authorized representatives of group and solo practitioners can access the 2014 Annual QRURs on the CMS Enterprise Portal using an Enterprise Identify Data Management (EIDM) account with the correct role. For more information on how to access the 2014 Annual QRURs, visit How to Obtain a QRUR.

Additional information about the 2014 QRURs and how to request an informal review is available on the 2014 QRUR website and through the QRUR Help Desk at or 888-734-6433 (select option 3).

NY Worker’s Compensation Board Proposes Regulation Changes
As of November 12, 2015, the following proposed regulation changes have been published to the Board’s website:

Amendment of 12 NYCRR 324.3 (Variances)

Amendment of 12 NYCRR 324.4 (Optional Prior Approval)

Amendment of 12 NYCRR 311.1 (Funeral Expenses)

Amendment of 12 NYCRR 325-1.4 (Authorization for Medical Services)

Amendment of 12 NYCRR 300.5 (Stipulations)

Repeal of 12 NYCRR 300.13, 300.15 and 300.16 and Addition of 12 NYCRR 300.13 (Administrative Review, Full Board Review and Reconsiderations)

Amendment of 12 NYCRR 300.27 (Meetings of the Board)

Amendment of 12 NYCRR 300.36 (Section 32 and Voluntary Binding Review)

The proposed regulation changes will be published in the November 10, 2015 edition of the State Register. Comments on the proposed regulations will be accepted for 45 days, from November 10, 2015 through December 28, 2015.

Please send questions or comments on the proposed regulations to: Heather M. MacMaster, Associate Attorney, Workers’ Compensation Board, 328 State Street, Schenectady, New York 12305-2318, telephone: (518) 486-9564, or email your comments to the Board

From NY Workers Compensation Board: December District Dialogue Sessions
Thank you to all who attended our Fall District Dialogue Sessions. We are very fortunate for everyone’s participation and contribution, making our District Dialogues a continued success. Please join us for our Winter 2015 District Dialogue Sessions. This will be the Board’s sixth District Dialogue Session since we began holding these sessions in September 2014. We hope you will join us at one of our District Offices. The locations, dates and times are as follows:

WC Schedule_Updated


*Due to the relocation of the Albany District Office, the Albany District Dialogue date is still to be determined. An update will be sent when a location, date and time are decided.

It will be here before you know, so be sure to mark your calendars! We look forward to seeing and hearing from you.

If you have any questions, please contact


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