Council Meeting – September 17, 2015

AGENDA
Council Meeting
Thursday, September 17, 2015
Long Island Marriott
101 James Doolittle Blvd.
Uniondale, NY 11553

A. Call to Order and Roll Call

B. Approval of the Council Minutes of June 18, 2015

C. New Business (All New Action & Informational Items)

1. President’s Report:

a. Hospital Outreach Update
b. Executive Committee Minutes of the MSSNY Executive Committee Teleconference, July 15, 2015
c. MSSNY, Academy of Family Physicians NY Chapter and NYS Radiological Society Letter to Commissioner Zucker re E-Prescribing Mandate
d. NYS Radiological Society/MSSNY – Letter to Katherine Ceroalo, House Counsel, Regulatory Affairs Unit, NYSDOH re comments regarding proposed State regulations affecting the practice of Radiologic Technology published in the NYS Register, July 29, 2015
e. Summary of Medicaid Value Based Purchasing Workgroup
f. CPH Resolution 200, Physician Burnout and Wellness Programs (For Council Approval)

2. Secretary’s ReportNominations for Life Membership & Dues Remissions

3. Board of Trustees Report – Dr. Latreille will present the report (handout at Council)

4. MSSNYPAC Report – Dr. Sellers will present the report (handout at Council)

5. MLMIC Update – Mr. Don Fager will present a verbal report

6. AMA Delegation Update – Dr. Kennedy will present a verbal update

7. MESF Update – Dr. Kleinman will present the report (handout at Council)

8. Commissioners (All Action Items )

1. Committee of Membership, Parag H. Mehta, MD
    Recommended Procedures for Handling
    Special Requests for Life Membership Special Request for Life Membership on behalf of
George Anstadt, MD
    Adopting a Dues Requirement for Physicians who become Life Members in the Future
(FOR COUNCIL APPROVAL)
2. Commissioner of Science and Public Health, Frank G. Dowling, MD
Recommendations for MSSNY from AMA Task Force to Reduce Opioid Abuse
(FOR COUNCIL APPROVAL)

9. Councilors (All Action Items from County Societies and District Branches)
No action items submitted

D. Reports of Officers (Informational)
1. Office of the President – Date of Discovery Meeting with Senate Staff (verbal report)
2. Office of the President-Elect – Malcolm D. Reid, MD, MPP
3. Office of the Vice President – Charles Rothberg, MD
4. Treasurer’s Report –Thomas J. Madejski, MD, FACP, Financial Statement for the period January 1, 2015 to August 31, 2015
5. Office of the Speaker – Kira A. Geraci-Ciradullo, MD, MPH

E. Reports of Councilors (Informational)

1. Kings Richmond Report – Parag H. Mehta, MD
2. Bronx / Manhattan Report Report – Joshua M. Cohen, MD, MPH
3. Nassau County Report – Paul A. Pipia, MD
4. Queens County Report – Saulius J. Skeivys, MD
5. Suffolk County Report – Frank G. Dowling, MD
6. Third District Report – Harold M. Sokol, MD
7. Fourth District Branch Report – John J. Kennedy, MD (No Report Submitted)
8. Fifth District Report –Howard H. Huang, MD
9. Sixth District Branch Report – Robert A. Hesson, MD
10. Seventh District Report – Mark J. Adams, MD
11. Eight District Report – Edward Kelly Bartels, MD
12. Ninth District Report – Thomas T. Lee, MD
13. Medical Student Section Report – Charles A. Kenworthy  (No Report Submitted)
14. Resident & Fellow Section Report – Robert A. Viviano, DO  (No Report Submitted)
15. Young Physician Section Report – L. Carlos Zapata, MD  (No Report Submitted)

F. Commissioners (All Committee & Sub-Committee Informational Reports/Minutes)

1. Commissioner of Science & Public Health, Frank G. Dowling, MD

2. Commissioner of Communications, Joshua M. Cohen, MD, MPH
            a. Communications Report                                   

G. Report of the Executive Vice President
1 .Membership Dues Revenue Schedule
2. State Coalition Conference Call, July 7, 2015
3. Physician Advocacy Council Meeting, July 21, 2015

H. Report of the General Counsel
     1. NYS Psychiatric Association v. United Healthgroup Decision
2. Request to submit an amicus brief (handout at Council)

I. Report of the Alliance
    1. Alliance Report

J. Other Information/Announcements

1. Draft AMA Comments on 2016 Physician Fee Schedule
2. Dr. Maldonado’s Press Statement – Proposed Insurer Mergers
3. AMA News Release Merger – Health Insurer Mergers
4. Whatley/Kallas Letter – Proposed Insurer Mergers
5. Letter from Commissioner Zucker re Grand Rounds
6. Joint Letter to NY Times editor re Op Ed on Lavern’s Law
7. EHR Survey
8. AMA-CMS Press Release re ICD-10
9. ACCME Announcment re American Board of Internal Medicine and Accreditation Council for CME     Announce Collaboration in Support of Physician Lifelong Learning
10. Medicare Payment Advisory Commission Letter to Andrew Slavitt, Acting Administrator Centers
      for Medicare and Medicaid Services
11. National Hispanic Health Foundation Letter – Leadership Award to Dr. Maldonado
12. Recipients of the Duane and Joyce Cady Physicians of Tomorrow Awards 

K. Adjournment

September 11, 2015 – AMA’S ANALYSES OF PROPOSED INSURANCE MERGERS

STATEMENT FROM MSSNY PRESIDENT JOSEPH MALDONADO, MD IN RESPONSE TO AMA’S ANALYSES OF PROPOSED INSURANCE MERGERS

“Today’s announcement by the American Medical Association analyzing the consequences of the proposed consolidation of the health insurance industry is a clarion call to our federal and state regulators to closely review the patient care implications of these proposed mergers.

Undoubtedly, the merger of Anthem (the parent of Empire BC/BS) with Cigna, and Aetna with Humana, will give these companies far greater market power to reduce physician and hospital choice for our patients by further restricting networks and moving towards more burdensome administrative requirements as a precondition of our patients receiving needed care.

In addition to preventing these mergers from going forward, policymakers need to enable physicians to better advocate on their patients’ behalf by enacting legislation (A.336, Gottfried S.1157, Hannon) to permit independently practicing physicians to come together to negotiate patient care terms with health insurers in regions where just a few plans dominate the delivery of care.”

Joseph R. Maldonado, Jr., MD, MSc, MBA, DipEBHC
President, Medical Society of the State of New York

Council – Sept. 17, 2015

AGENDA
Council Meeting
Thursday, September 17, 2015
Long Island Marriott
101 James Doolittle Blvd.
Uniondale, NY 11553

A. Call to Order and Roll Call

B. Approval of the Council Minutes of June 18, 2015

C. New Business (All New Action & Informational Items)

1. President’s Report:

a. Hospital Outreach Update
b. Executive Committee Minutes of the MSSNY Executive Committee Teleconference, July 15, 2015
c. MSSNY, Academy of Family Physicians NY Chapter and NYS Radiological Society Letter to Commissioner Zucker re E-Prescribing Mandate
d. NYS Radiological Society/MSSNY – Letter to Katherine Ceroalo, House Counsel, Regulatory Affairs Unit, NYSDOH re comments regarding proposed State regulations affecting the practice of Radiologic Technology published in the NYS Register, July 29, 2015
e. Summary of Medicaid Value Based Purchasing Workgroup
f. CPH Resolution 200, Physician Burnout and Wellness Programs (For Council Approval)

2. Secretary’s ReportNominations for Life Membership & Dues Remissions

3. Board of Trustees Report – Dr. Latreille will present the report (handout at Council)

4. MSSNYPAC Report – Dr. Sellers will present the report (handout at Council)

5. MLMIC Update – Mr. Don Fager will present a verbal report

6. AMA Delegation Update – Dr. Kennedy will present a verbal update

7. MESF Update – Dr. Kleinman will present the report (handout at Council)

8. Commissioners (All Action Items )

1. Committee of Membership, Parag H. Mehta, MD
    Recommended Procedures for Handling
    Special Requests for Life Membership Special Request for Life Membership on behalf of
George Anstadt, MD
    Adopting a Dues Requirement for Physicians who become Life Members in the Future
(FOR COUNCIL APPROVAL)
2. Commissioner of Science and Public Health, Frank G. Dowling, MD
Recommendations for MSSNY from AMA Task Force to Reduce Opioid Abuse
(FOR COUNCIL APPROVAL)

9. Councilors (All Action Items from County Societies and District Branches)
No action items submitted

D. Reports of Officers (Informational)
1. Office of the President – Date of Discovery Meeting with Senate Staff (verbal report)
2. Office of the President-Elect – Malcolm D. Reid, MD, MPP
3. Office of the Vice President – Charles Rothberg, MD
4. Treasurer’s Report –Thomas J. Madejski, MD, FACP, Financial Statement for the period January 1, 2015 to August 31, 2015
5. Office of the Speaker – Kira A. Geraci-Ciradullo, MD, MPH

E. Reports of Councilors (Informational)

1. Kings Richmond Report – Parag H. Mehta, MD
2. Bronx / Manhattan Report Report – Joshua M. Cohen, MD, MPH
3. Nassau County Report – Paul A. Pipia, MD
4. Queens County Report – Saulius J. Skeivys, MD
5. Suffolk County Report – Frank G. Dowling, MD
6. Third District Report – Harold M. Sokol, MD
7. Fourth District Branch Report – John J. Kennedy, MD (No Report Submitted)
8. Fifth District Report –Howard H. Huang, MD
9. Sixth District Branch Report – Robert A. Hesson, MD
10. Seventh District Report – Mark J. Adams, MD
11. Eight District Report – Edward Kelly Bartels, MD
12. Ninth District Report – Thomas T. Lee, MD
13. Medical Student Section Report – Charles A. Kenworthy  (No Report Submitted)
14. Resident & Fellow Section Report – Robert A. Viviano, DO  (No Report Submitted)
15. Young Physician Section Report – L. Carlos Zapata, MD  (No Report Submitted)

F. Commissioners (All Committee & Sub-Committee Informational Reports/Minutes)

1. Commissioner of Science & Public Health, Frank G. Dowling, MD

2. Commissioner of Communications, Joshua M. Cohen, MD, MPH
            a. Communications Report                                   

G. Report of the Executive Vice President
1 .Membership Dues Revenue Schedule
2. State Coalition Conference Call, July 7, 2015
3. Physician Advocacy Council Meeting, July 21, 2015

H. Report of the General Counsel
     1. NYS Psychiatric Association v. United Healthgroup Decision
2. Request to submit an amicus brief (handout at Council)

I. Report of the Alliance
    1. Alliance Report

J. Other Information/Announcements

1. Draft AMA Comments on 2016 Physician Fee Schedule
2. Dr. Maldonado’s Press Statement – Proposed Insurer Mergers
3. AMA News Release Merger – Health Insurer Mergers
4. Whatley/Kallas Letter – Proposed Insurer Mergers
5. Letter from Commissioner Zucker re Grand Rounds
6. Joint Letter to NY Times editor re Op Ed on Lavern’s Law
7. EHR Survey
8. AMA-CMS Press Release re ICD-10
9. ACCME Announcment re American Board of Internal Medicine and Accreditation Council for CME     Announce Collaboration in Support of Physician Lifelong Learning
10. Medicare Payment Advisory Commission Letter to Andrew Slavitt, Acting Administrator Centers
      for Medicare and Medicaid Services
11. National Hispanic Health Foundation Letter – Leadership Award to Dr. Maldonado
12. Recipients of the Duane and Joyce Cady Physicians of Tomorrow Awards 

K. Adjournment

September 11, 2015 – NYT Prints MSSNY/GNYHA Letter to Ed

NYRX
drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lgTwitter_logo_blue1
September 11, 2015
Volume 15, Number 34

Dear Colleagues:

Yesterday, the New York Times published a letter to the editor written by Ken Raske, president of the GNYHA and me.  The original op-ed, written by two attorneys, supported Lavern’s Law which sought expansion of dates of discovery.

To the Editor:

Re “Legislative Malpractice,” by Thomas Moore and Steve Cohen (Op-Ed, Aug. 31):New York’s medical malpractice system needs comprehensive reforms. The writers note that many states allow patients to file suit based on when they discover that there was a medical error, but, unlike New York, most of those states also have caps on damages and other laws that balance the effects of wider discovery rules. Pegging New York’s statute of limitations to a patient’s subjective knowledge will potentially lead to far more claims and greater financial exposure for the state’s doctors and hospitals.

Despite scoring high on various quality indicators, New York’s hospitals and doctors have among the highest medical malpractice costs in the United States. Many doctors logically conclude that the state is simply too hostile an environment to practice medicine.

Finally, the same study that the writers cite to blame hospitals and doctors (“To Err is Human) emphasizes that improving patient safety requires a shift away from a culture of blame. Other studies have concluded that the drivers of malpractice liability are varied and not necessarily related to the quality of care.

Medical malpractice is a complex issue that deserves thoughtful discourse. Only through comprehensive reform — not narrow, piecemeal legislation — can we achieve appropriate balance and minimize inequities.

KENNETH E. RASKE­
JOSEPH R. MALDONADO Jr

­The writers are presidents of the Greater New York Hospital Association and Medical Society of the State of New York, respectively.

Please send your comments to comments@mssny.org


MLMIC



Excellus BCBS Target of Cyberattack; 7M People Affected
On Sept. 9, Excellus BlueCross BlueShield announced that its Information Technology (IT) systems were the target of a sophisticated cyberattack and steps are being taken for the protection of its members and individuals who do business with the health plan.

As a result of cyberattacks on other insurance companies, Excellus BCBS engaged FireEye’s Mandiant incident response division, one of the world’s leading cybersecurity firms, to conduct a forensic assessment of its IT systems. On August 5, 2015, Excellus BCBS learned that cyber attackers gained unauthorized access to its IT systems.

The investigation has not determined that personal information on the company’s IT systems was removed or used inappropriately. However, the investigation has determined that attackers may have gained unauthorized access to approximately 7 million individuals’ information, which could include name, date of birth, Social Security number, mailing address, telephone number, member identification number, financial account information and claims information.

Excellus BCBS is beginning to mail letters to affected individuals today and is providing two years of free identity theft protection services through Kroll, a global leader in risk mitigation and response solutions, including credit monitoring powered by TransUnion. A dedicated call center also has been set up for members and other affected individuals. And, the company has established a dedicated website (www.excellusfacts.com), where members and other affected individuals can view frequent questions and answers and sign up for the free credit monitoring service and identity theft protection services. Individuals who believe they are affected by this cyberattack but who have not received a letter by November 9, are encouraged to call the number listed at that website.


WCB Issues Guidance for Complying With ICD-10 as of October 1
The New York State Workers Compensation Board today issued a bulletin to set forth how it will implement the use of ICD-10 codes as of October 1. To read the bulletin, click here.

The bulletin notes that “to promote consistency between medical systems and to avoid imposing significant costs to support multiple systems, the Board will require use of ICD-10 consistent with CMS for dates of service after 10/1/15. In particular, the Bulletin notes the following:

• Providers may not submit a combination of ICD-9 and ICD-10 codes on the same bill. Separate bills must be submitted for dates of service on or before September 30, 2015 and on or after October 1, 2015.
• In the event a provider has not completed the full transition to ICD-10, medical bills shall be processed and paid regardless.

• Carriers must accept both ICD-9 codes and ICD-10 codes effective October 1, 2015. Provider miscoding, such as the use of ICD-9 codes for dates of service on or after October 1, 2015, or the use of ICD-10 codes for dates of service prior to October 1, 2015, are not valid reasons to deny or reduce a medical bill.

• In order to ease the transition to ICD-10, the Board will accept the CMS-1500 (or HCFA-1500) form with a detailed narrative report or office note effective October 1, 2015. Authorized physicians, podiatrists, and chiropractors statewide may submit a CMS-1500 with a detailed narrative report or office note in lieu of C-4 or C-4.2 forms. If a CMS-1500 is submitted without the detailed narrative report or office note, it is not a valid bill submission. A narrative report or office note is considered detailed when it contains the necessary information for the insurance carrier to properly process the submission. The narrative attachment requirements can be found on the Board’s website.


Dr. Maldonado: More Mergers Provide Less Choice
The transition from five major health insurers to three would “erode competition” across the country in major metropolitan markets, including New York, the American Medical Association said yesterday. The Chicago group asserts that the Anthem-Cigna and Aetna-Humana mergers would slash competition in 154 metro areas in 23 states. Only the Anthem-Cigna union would have a notable impact on New York’s commercial insurance market, according to the AMA analysis: Competition in the combined HMO, PPO and POS markets would fall about 12%. The report used a method to measure market competition called the Herfindahl-Hirschman Index. The Anthem-Cigna deal would give the state an HHI score of 1,921—still well within the range of a moderately concentrated market. Scores below 1,500 are considered unconcentrated, and, above 2,500, highly concentrated. The mergers “will give these companies far greater market power to reduce physician and hospital choice for our patients receiving needed care,” said Dr. Joseph Maldonado, president of Medical Society of the State of New York. (Crain’s 9/9/15) 


Key New York Congressman Backs Fair Medicare Audits Legislation
Western New York Congressman Chris Collins has joined on as a co-sponsor of HR 2568, for the Fair Medical Audits Act of 2015, legislation supported by several state medical societies to increase the transparency of Medicare Recovery Audit Contractor (RAC) audits.  Rep. Collins is a member of the US House of Representatives Energy & Commerce Health Subcommittee.  As noted by the Physicians Advocacy Institute, the legislation, sponsored by Rep. George Holding (R-NC), would:

  • Makes the audit process much more transparent. The FMAA requires RACs to provide pre-audit notification and post audit reporting to physicians and other health care providers regarding specific information relating to an audit. Increasing transparency will help address confusion and create a more educational audit process by helping physicians to better understand audit findings and reduce the risk of repeated errors.
  • Establishes more rigorous qualifications for RAC officials performing claim reviews. The complex nature of medical audits and the need to address the high reversal rate for appealed overpayment determinations warrant more rigorous qualifications for RAC reviewers.
  • Increases accountability of RACs for Inaccurate findings. The current system is a bounty hunter approach that creates financial incentives for auditors to make overzealous and often-inaccurate audit findings. FMAA establishes financial penalties for RACs for inaccurate audit findings, while creating new incentive payments for RACs who voluntarily educate providers on common errors.
  • Delays payment to auditors until after an external appeal. The FMAA would delay RAC payments until claims are subject to external review – currently the third level of appeal – to help ensure providers are not subject to premature and unfair recoupment.
  • Promotes more targeted documentation requests by RAC auditors. Physician practices have struggled with the administrative and financial burdens that RAC correspondence and production requests often impose. The FMAA would help to address this by compensating providers for certain documentation requests.
  • Requires a sound extrapolation formula for determining overpayment amounts and shortens “look-back” period from 4 years to 2 years. Shortening the look-back period to 2 years would more effectively address the appeals backlog and provide much-needed administrative relief for providers. 


Press-Ganey: Patients Like Healthcare Teamwork and Clean Rooms
A health care team’s ability to work together is a major factor in hospital inpatient ratings linked to loyalty, according to an analysis more than 1 million HCAHPS responses by Press Ganey, the largest patient-experience consulting firm http://bit.ly/1KHJnS8

Of inpatients who believed staff worked well together, 87% gave their experience high ratings;36.7% of patients who did not think staff were coordinated gave top ratings overall. In hospitals, once teamwork was accounted for, room cleanliness emerged as a major ratings driver. Regarding emergency room care, empathy for patient concerns and communication about delays and pain management were most highly related with a patient’s likelihood to recommend the facility. In outpatient facilities, confidence in the clinician, along with effective care coordination and empathy, were paramount. 


AMA Report Highlights Concerns of Proposed Health Insurer Consolidation, including New York; MSSNY Issues Statement
The American Medical Association released a study this week raising an alarm with the significantly enhanced health insurer market concentration that would arise within14 states across the country, including New York State, if the recently announced proposed merger of Anthem and Cigna was permitted to go forward.  To read more, click here. The report also discussed the enhanced market concentration in several states across the country as a result of the proposed merger of Aetna and Humana, though no specific consequences for New York State were noted.

The report and its possible consequences on patients and physicians were highlighted in an article in the New York Times.

Moreover, the issue of the consequences of insurer consolidation was the subject of a House Judiciary Committee hearing this week.

The AMA report noted that the proposed Anthem-Cigna merger would be presumed to significantly enhance the market power of the combined company for the entire commercial market in Long Island, as well as raising significant competitive concerns in New York City and the Hudson Valley.  As a result, MSSNY President Dr. Joseph Maldonado gave the following press statement which was reported in Politico New York and Crains’ Health Pulse regarding the need to better level the playing field between market dominant insurers and physicians advocating on behalf of their patients:

“Today’s announcement by the American Medical Association analyzing the consequences of the proposed consolidation of the health insurance industry is a clarion call to our federal and state regulators to closely review the patient care implications of these proposed mergers.

Undoubtedly, the mergers of Anthem (the parent of Empire BC/BS) with Cigna, and Aetna with Humana, will give these companies far greater market power to reduce physician and hospital choice for our patients by further restricting networks and moving towards more burdensome administrative requirements as a precondition of our patients receiving needed care.

In addition to preventing these mergers from going forward, policymakers need to enable physicians to better advocate on their patients’ behalf by enacting legislation (A.336, Gottfried S.1157, Hannon) to permit independently practicing physicians to come together to negotiate patient care terms with health insurers in regions where just a few plans dominate the delivery of care.” 


 “Many Faces of Flu” CME Webinar on October 21; Registration Now Open
MSSNY will begin its 2016 Medical Matters continuing medical education (CME) webinar series with “Many Faces of Flu 2015” on Wednesday, October 21, 2015 at 7:30 a.m.   William Valenti, MD, chair of MSSNY Infectious Disease Committee and a member of the Emergency Preparedness and Disaster/Terrorism Response Committee will serve as faculty for this program. Registration is now open for this webinar here.

Educational objectives are: 1) Recognize the distinction between seasonal, Avian and Pandemic flu; 2) Describe clinical and laboratory diagnostic features and treatment; 3) Identify recommended immunizations and antiviral medications for treatment.   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.

A copy of the flyer can be accessed here.  Additional information or assistance with registration may be obtained by contacting Melissa Hoffman at mhoffman@mssny.org.

Medical Matters is a series of CME webinars sponsored by MSSNY’s Committee on Emergency Preparedness and Disaster/Terrorism Response.  Additional programs will be conducted in January-May 2016 and topics include: public health preparedness; immunizations and recommendations during a disaster; and radiological emergencies.  Program dates for Medical Matters will be announced shortly.


Get Ready Now: Assess How ICD-10 Will Affect Your Practice
With ICD-10 less than 30 days away, now is the time to get ready. You can make sure your practice is prepared by following the ABCs of ICD-10:

  • Assess how ICD-10 will affect your practice and make a plan
  • Be sure your systems are ready
  • Contact your vendors 

Access to ICD-10 codes – You can find codes from a variety of sources, including:

  • Code books
  • CD/DVD and other digital media
  • Online (e.g., go to cms.gov/ICD10 and select “2016 ICD-10-CM and GEMS” to download 2016 Code Tables and Index)
  • Practice management systems
  • Electronic health record (EHR) products
  • Free and low-cost smartphone apps
  • CMS ICD-10 Code Lookup
  • Coding Conversion Tool 

Clearinghouse services – Some providers who are not ready could benefit from contracting with a clearinghouse to submit claims.

  • Clearinghouses can help by:
    • Identifying problems that lead to claims being rejected
    • Providing guidance about how to fix rejected claims (e.g., more or different data need to be included)
  • Clearinghouses cannot help you code in ICD-10 codes unless they offer third-party billing/coding services.

Clinical documentation and coding training

  • Train staff on ICD-10 fundamentals using the wealth of free resources from CMS, which include the ICD-10 website, Road to 10, Email Updates, National Provider Calls, and webinars. Free resources are also available from:
    • Medical societies, health care professional associations
    • Hospitals, health systems, health plans, vendors
  • Training for clinical staff—e.g., physicians, nurse practitioners, physician assistants, registered nurses—should focus on documentation, new coding concepts captured in ICD-10.
  • Training for coding and administrative staff—e.g., coders, billers, practice managers—should focus on ICD-10 fundamentals.

New forms – It is crucial to update hard-copy and electronic forms (e.g., superbills, CMS 1500 forms).

Systems upgrades – Double check that you’ve identified all systems that use ICD codes and need upgrades (e.g., practice management systems, electronic health record (EHR) products).

  • Call your vendors to confirm the ICD-10 readiness of your practice’s systems
  • Confirm that the health plans, clearinghouses, and third-party billing services you work with are ICD-10 ready
  • Ask vendors, health plans, clearinghouses, and third-party billers about testing opportunities
  • Transition costs for small medical practices could be substantially lower than projected earlier:
    • Many EHR vendors are including ICD-10 in their systems or upgrades—at little or no cost to their customers
    • Software and systems costs for ICD-10 could be minimal for many providers\


NYS DOH Announces New Vaccine Rules for Children Entering School
The NYS-DOH announced new vaccine rules for school children. Children in New York schools must now receive two doses of the measles, mumps, rubella vaccine, before entering school. Children in grades K-5 need five doses of DTaP, and children entering kindergarten and grades 1, 6 and 7 must have four doses of polio vaccine.  Previously, kindergarteners were allowed to attend school before completing the MMR DTaP and polio vaccine series. The new regulations follow recommendations from the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (ACIP). A physician letter on these changes was issued on August 26, 2015 from Elizabeth Rausch-Phung, MD, MPH, NYS DOH, Director, Bureau of Immunization and is available here.  Additional information on the regulatory changes may be obtained here.


CMS Releases 2014 QRURs and PQRS Reports
On September 9, 2015 CMS released the 2014 Quality and Resource Use Reports (QRURs) and 2014 Physician Quality Reporting System (PQRS) Feedback Reports. The 2016 PQRS and Value Modifier (VM) payment adjustments are based on 2014 reporting. For groups with 10 or more PQRS-eligible professionals (EPs) that are subject to the 2016 Value Modifier, the QRUR shows how the VM will affect Medicare’s 2016 payments to physicians. VM cost and quality scores will also be provided in the QRURs for other practices even though they are not yet subject to the VM. If physicians or group practices feel an incentive payment or penalty was performed in error they must file an Informal Review by November 9, 2015.

2014 EHR and QCDR Data Issues

 As reported in the September 3, 2015 Advocacy Update Issue, CMS discovered various errors with the  2014 Physician Quality Reporting System (PQRS) data submitted by vendors on behalf of EPs and group practices that reported via electronic health records (EHR) and qualified clinical data registries (QCDR). CMS has stated there will be no need for physicians or group practices to submit a PQRS Informal Review request.

Because of the errors, the EHR and some of the QCDR data is inconsistent. Due to these errors, CMS will not post PQRS performance data for the affected practices on Physician Compare.  However, determination of PQRS and Meaningful Use payment will not be affected because they are based solely on whether the practice successfully reported rather than on their actual performance—simply receiving the data will allow CMS to deem a physician or group practice as successful for purposes of avoiding a payment adjustment in 2016 or for receiving a 2014 incentive.

For the value modifier, which involves calculating actual quality scores in addition to determining whether quality measures were reported, CMS has acknowledged the vendor data errors may create problems. Specifically, CMS will not be able to accurately calculate the PQRS portion of the Quality Composite Score. Instead, the quality score will be based solely on the claims-based outcomes measures and the Consumer Assessment of Healthcare Providers and Systems Survey, if applicable.

2014 PQRS Data Submission Problems

 The AMA is aware of instances in 2014 where physicians and practices mistakenly registered for the PQRS group practice reporting option (GPRO) submission mechanism and/or at the last minute their EHR vendor would not support their preferred submission mechanism.  These groups or individuals, will have to file an Informal Review by November 9, 2015. We have been told this only affects a very small percentage of EPs and practices.

How to Access the Reports and File an Informal Review

 In order to access the portal to review reports and/or file an Informal Review,  an EIDM account is required. CMS transitioned the portal from the Individual Access to CMS Computer Services (IACS) to the Enterprise Identity Management System (EIDM) on July 13, 2015. The IACS system is now retired, but current PQRS and VM IACS users, their data, and roles have moved to EIDM, which is accessible from the portion of the CMS Enterprise Portal at http://portal.cms.gov. The EIDM system provides a way for business partners to apply for, obtain approval for, and receive a single user ID for accessing multiple CMS applications.

For more information on 2014 feedback reports and how to request them, see: How to Obtain a QRUR.


E-PRESCRIBING of All Substances Required By March 27, 2016
Physicians and other prescribers are reminded that New York State’s e-prescribing requirements for non-controlled and controlled substances will go into effect on March 27, 2016.The NYS Department of Health’s Bureau of Narcotic Enforcement has provided information to physicians and other prescribers to assist them in their transition to electronic prescribing. Practitioners should continue their efforts to become compliant with the law, including working with their software vendors to implement the additional security requirements needed for e-prescribing of controlled substances (EPCS), and registering their certified software applications with the Bureau of Narcotic Enforcement.   According to state officials, over 22,000 prescribers have registered their systems with DOH.

DrFirst and MSSNY have partnered to bring MSSNY members the industry’s leading e-prescribing solution at a special discounted price and information on this program can be found here: http://www.drfirst.com/mssny/mssny-lp

For physicians who prescribe controlled substances, there are additional steps to complete in order to electronically prescribe controlled substances.  These include the following:

  • First, the software you currently use must meet all the federal security requirements for EPCS, which can be found on the Drug Enforcement Agency’s (DEA) web page. http://www.deadiversion.usdoj.gov/ecomm/e_rx/

Note that federal security requirements include a third party audit or DEA certification of the software.

  • Second, you must complete the identity proofing process as defined in the federal requirements.
  • Third, you must obtain a two-factor authentication as defined in the federal requirements.
  • Fourth, you must register your DEA certified EPCS software with the Bureau of Narcotic Enforcement (BNE). Registration instructions are included in the FAQs.

A copy of the BNE’s Frequently Asked Questions (FAQs) can be found here.

EPCS systems must be registered through the ROPES system.  ROPES stands for: Registration for Official Prescriptions and E-Prescribing Systems. To access ROPES, use the following steps:

  • Login to the Health Commerce System (HCS) at https://commerce.health.state.ny.us
  • Under “My Content” click on “All Applications”
  •  Click on “R”
  •  Scroll down to ROPES and double click to open the application. You may also click on the “+” sign to add the application “ROPES” under “My Applications” on the left side of the screen.

EPCS became permissible in New York State and over 90% of the pharmacies can now accept e-prescribing for controlled substances, according to officials from BNE.

There will be a waiver process for those physicians who experience technological or financial issues, however, DOH has not yet released this process, but it is expected to do so before January 1. The waiver process will be electronic. Waivers will be provided for a facility, a large medical practice or an individual physician. The law provides that physicians may apply for a waiver of this e-prescribing requirement as a result of a) economic hardship b) technological limitations that are not reasonably within the control of the physician, or c) other exceptional circumstance. OH has indicated that more information on the waiver process will be available shortly.

E-prescribing of non-controlled substances is also required under the law; however, registering of this system with the state is not necessary.

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.

Information regarding e-prescribing may be accessed at the following links:

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

http://www.op.nysed.gov/prof/pharm/pharmelectrans.htm 


Alzheimer’s Disease & Advance Directives Webinar to Be Held On September 17
The Albany School of Public Health will hold a free education webinar on Alzheimer’s Disease & Advance Directives: A Primer for Primary Care Physicians on Thursday, September 17th from 9-10 a.m.

Learning objectives are: 1)  Discuss the dramatic impact that the growing number of new Alzheimer’s patients has on both patients and caregivers 2) Describe healthcare providers’ professional obligation within their window of opportunity to have and document conversations with patients with remaining capacity about advance directives and 3) Identify the criteria for determining capacity.  The program will be conducted by Wayne Shelton, PhD, MSW, Professor of Medicine and Bioethics, Alden March Bioethics Institute, Albany Medical College and Kevin Costello, MD, Assistant Professor of Medicine and

Attending, Department of Medicine, Albany Medical College. The program will provide critical information and tools to prepare physicians and healthcare providers to have constructive conversations with patients that have remaining capacity about their preferences for medical care in the advance stage of disease.  Continuing medical education credits are available.   To register go to: www.phlive.org


CLASSIFIED

HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914

House

Pain Medicine Practice for Sale
Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a “turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 

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 / drdese@gmail.com.

 

OFFICE SPACE – 1185 Park Ave. (94th St.)
Full-time. Ideal for busy medical subspecialty. Exclusive use of consult, exam room.  Stress test, echo available. Beautiful décor. Public transportation nearby. Available immediately. Please call 212-996-2900 or e-mail: robertreichsteinmd@gmail.com



CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

August 28, 2015 – New Premiums – More for Less

NYRX
drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 28, 2015
Volume 15, Number 33

Dear Colleagues:

This week, the Wall Street Journal reported a story about rising healthcare premiums.  While President Obama expected that premium rate increase requests would come in “significantly lower” than what was then being requested, reality has proven his expectations wrong.  The story reports a premium rate increase of over 36% for a Blue Cross Blue Shield product in Tennessee. The White House rationalizes that this is still better than what was previously available.  Patients now have the option of enrolling with other products. In New York, we are beginning to realize, this usually means purchasing insurance products that offer less.  They come at a lower premium but often carry higher deductibles and have narrower networks with stringent accessing protocols.

The story reinforces the lessons I learned from my advisors and professors Bent Flyvbjerg and Paolo Quattrone when I was at Oxford.  Bent’s expertise lies in understanding why megaprojects fail to deliver on time, on budget and on-agenda.  He proposes that their failure is due to “optimism bias” and “strategic misrepresentation.” Quattrone proposes that when numbers are proposed to us in accounting reports, one should look at what is NOT being presented to understand where the real agenda lies. Accounting reports tell you what the writer wishes to tell you and not what is necessarily financially driving the organization.  These lessons are critical to understand if we are to fully comprehend where we are going on the healthcare transformation train.

Language Couches Reality

          Many, in the sincere hope of changing the flaws of our healthcare system, have succumbed to the rhetoric of the “optimism bias”— its effective language; its painted a rosy picture and emotionally evocative narratives painting an illusion of better quality and access to care.  From the trenches, we hear otherwise.  We hear the stories of patients feeling a highly impersonal healthcare engagement that is driven by process and outcomes.  The person within the patient is no longer a priority of the art of medicine, there is no art – there’s merely science and technology.

When the optimism bias is not being engaged, the more nefarious strategic misrepresentation is being utilized. Quattrone presents this as very legitimate accounting processes that artfully hide the truth of the impending dangers.  We see these every day— reports that project losses and justify premium hikes while healthcare corporate officers rake in reprehensible salaries.

How do we respond to this optimism bias, strategic misrepresentation and to the “maieutic” machine?

MSSNY is currently advocating for collective negotiations capabilities for physicians and exploring other mechanisms within safe harbor regulations that allow for greater collaboration in the efforts to bring about meaningful healthcare reform.

In the interim, each of us must individually weigh whether or not we will continue to play in the sandbox.

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

Please send your comments to comments@mssny.org


MLMIC



NYS Kindergarten Students Must Have Complete Set of Vaccinations
Effective Sept. 1, New York state pupils “entering kindergarten can no longer wait until age seven before parents demonstrate a completed series of vaccinations against highly contagious childhood infections, state health officials” announced on Aug. 27. The new rule will “require full doses of specific vaccines” before youngsters are allowed to go to kindergarten. In a statement yesterday, New York State Health Commissioner Howard Zucker, MD, JD, said, “These revisions are based on the most current science and will give our children the best protection we can provide from devastating diseases.”

NY Medical Students Honored with AMA Foundation MSSNY/Dr. Duane and Joyce Cady Physicans of Tomorrow Awards
This week, the AMA Foundation presented MSSNY/Dr. Duane and Joyce Cady Physicians of Tomorrow Awards to rising fourth-year medical students Victor Hoang, Natasha Ramsey and Michelle Smith. Each recipient was nominated by their medical school and will receive a $10,000 scholarship recognizing academic achievement.

Victor Hoang, a student at Touro College of Osteopathic Medicine, has spent summers working with Project Vietnam, building clinics and providing medical care for underserved villages in Vietnam. He has been awarded a Welch Scholars Grant in recognition of leadership, research, and academic achievement. While a student at Touro, Hoang has served as the president of the Obstetrics and Gynecology Student Organization. He earned a bachelor’s degree in molecular environmental biology from the University of California Berkeley.

Natasha Ramsey, a student at New York University School of Medicine, is pursuing a dual MD/MPH degree. She founded the Students Teaching About Real Subjects (STARS) Program, an all-girls health group dedicated to creating a safe environment to discuss topics surrounding sexual health. Ramsey also volunteers with the FOCUS program, mentoring NYU undergraduates who are first-generation college and/or minority students. Ramsey earned a bachelor’s degree in public health from Rutgers University.

Michelle Smith, a student at the University of Buffalo School of Medicine and Biomedical Sciences, was awarded the John and Janet Sung Scholarship for incoming first-year University at Buffalo medical students who demonstrate academic merit, need, and compassion for medicine. She served as fundraising chair and community service chair for the Medical Society of the State of New York (MSSNY). She led MSSNY’s partnership with St. Jude Children’s Hospital to create a statewide event benefitting New York state pediatric oncology patients. Smith graduated summa cum laude from Siena College in Loudonville, NY with a bachelor’s degree in biology.

The Physicians of Tomorrow Awards were created in 2004 to provide financial assistance to medical students facing spiraling medical school debt. On average, medical students in the U.S. graduate with a debt load of nearly $162,000. A large debt burden may deter many from practicing in underserved areas of the country or practicing primary care medicine. To date, over 1 million has been granted to exceptional medical students across the nation. 

Cuomo Announces Awards to Academic Medical Institutes
On August 27, Governor Cuomo announced $17.2 million in state awards to 26 academic medical institutions for the training of new clinical researchers working on cutting-edge biomedical research. These awards, administered over a two year period through the Empire Clinical Research Investigator Program, are vital to helping New York both attract new researchers and solidify itself as a national biomedical research hub.

Over the next two years, more than 86 physician researchers will be trained as a result of this funding in diverse research fields, including: heart and kidney disease, traumatic brain injury, human cancer genomics, health information technology, population health, and stem cell therapy. Once program researchers conclude their training through this program, they will be well prepared for careers in research.

The program supports two types of awards — team-based Center Awards and Individual Awards. Center Awards provide funding for teaching hospitals to form research teams focused on a specific topic, disease, or condition. This will not only further the development of clinician researchers, but also give these hospitals a foundation from which they can seek additional funding from the federal government to build upon their work.

Twelve institutions will receive Center Awards, with each receiving $1,260,332 over two years for the training of a team comprised of at least six fellows. For five of the 12 Center Award recipients, the awards will support both a primary and secondary project, and all 12 institutions have each committed at least $200,000 in direct matching funds for their projects.

Individual Awards are being made to 14 teaching hospitals, each of which will receive up to $150,000 over two years, to train program researchers in diverse research fields such as obesity, diabetes, lupus, kidney transplant, schizophrenia, HPV infection, and hearing loss.

The winners are as follows:

Center Awards 

  • HealthAlliance Hospital (Mid-Hudson)
  • Lincoln Medical and Mental Health Center (NYC)
  • Memorial Sloan-Kettering Cancer Center (NYC)
  • Montefiore Medical Center (NYC)
  • Mount Sinai Hospital (NYC)
  • New York Presbyterian – Columbia University (NYC)
  • New York Presbyterian – Weill Cornell Medical College (NYC)
  • North Shore University Hospital (Long Island)
  • NYU Langone Medical Center (NYC)
  • SUNY Downstate (NYC)
  • Westchester Medical Center (Mid-Hudson)
  • University of Rochester Medical Center (Finger Lakes)

Individual Awards

  • Elmhurst Hospital Center (NYC)
  • Erie County Medical Center (Western NY)
  • Hospital for Special Surgery (NYC)
  • Kings County Hospital Center (NYC)
  • Lenox Hill Hospital – North Shore LIJ Health System (NYC)
  • Long Island Jewish Medical Center – North Shore LIJ Health System (NYC)
  • Maimonides Medical Center (NYC)
  • Montefiore/New Rochelle (Mid-Hudson)
  • Mount Sinai Beth Israel (NYC)
  • New York Eye and Ear Infirmary of Mount Sinai (NYC)
  • New York Hospital Queens (NYC)
  • New York Methodist Hospital (NYC)
  • Staten Island University Hospital – North Shore LIJ Health System (NYC)
  • Winthrop University Hospital (Long Island)For more information on the Empire Clinical Research Investigator Program visit:http://www.health.ny.gov/professionals/doctors/graduate_medical_education/ecrip.

Members Only: Your Patients Can Save Up to 75% on Prescriptions
With the rising cost of both generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% onprescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!

Feds Rule that HHS Can Use Geography as Basis for Payments
Federal law gives HHS “flexibility and discretion” in calculating the reimbursement rate for providers in different geographic areas based on local wages, a federal appeals court judge has ruled on August 15.

A federal appeals court’s rejection this month of a lawsuit challenging the way the U.S. Department of Health and Human Services calculated the Medicare reimbursement rates in 2006 and 2007 sends a clear message to healthcare leaders: Don’t expect Medicare to change its ways to keep things fair.

The lawsuit was filed by 41 New England hospitals seeking $24 million in damages from what they argued were unreasonably low reimbursement rates. More specifically, the hospitals contested the HHS secretary’s decision in 2005 to change the boundaries of the geographic areas used to compute regional wage indices.

The wage indices are critical to hospital reimbursement rates because the cost of providing care can vary significantly depending on where a hospital is located, the hospitals explained in their complaint. An influential factor is the wages paid to hospital employees, which fluctuate based on the cost of living in different geographic areas.

To help compensate for those disparities, HHS annually computes a wage index that compares hospital wages within defined geographic areas to a national average, and adjusts Medicare reimbursements accordingly.

When the wage indices were computed in 2006 and 2007, the geographic boundary lines fell in a way that left three multi-campus hospitals straddling different geographic areas. Those multi-campus hospitals were deemed to be merged facilities operating as a single institution, and thus applied their combined wage data to the wage index for the main provider’s geographic area.

Groups Recommend Early Exposure to Peanuts to Prevent Allergies
A consensus statement developed and endorsed by the American Academy of Pediatrics and the American Academy of Allergy, Asthma & Immunology recommends that “infants at high risk of peanut allergies be given foods containing peanuts before they turn 1.” The recommendations stem from “a major allergy” study published this year that indicated that “exposure to peanuts in infancy seemed to help build tolerance — contrary to conventional thinking.” The statement will be published in Pediatrics.

August 26, 2015

Veterans Affairs Report: Still Not Enough Psychiatrists
A report (pdf) from the Department of Veterans Affairs’ (VA) inspector general (IG) http://www.va.gov/oig/pubs/VAOIG-13-03917-487.pdf finds that even after an extensive hiring push, the agency still has an insufficient number of full-time psychiatrists to keep up with demand and current staff is not being used efficiently.

CLASSIFIED

HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914

House

Pain Medicine Practice For Sale
Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a “turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 

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 / drdese@gmail.com.

Home / Office – Baldwin, Nassau County, South Shore, Long Island 11510
Exceptionally well-built Split Level with 4 floors of living plus a 5-room professional suite on the ground level with a separate entrance. Office consists of a waiting room, Dr.’s consultation office, secretary’s office, 2 examination rooms plus ½ bathroom.

Home offers 3 bedrooms, 2 full plus ½ bathrooms, living room w/ vaulted ceilings, formal dining room, eat-in-kitchen, huge family room with access to a 12×17 outside enclosed porch with bluestone pavers, central air conditioning, gas heat, all hardwood flooring, fireplace, custom crafted bookcases and shelving, full finished basement and a detached 2.5 car garage. Driveway has turn-around ability with ample street parking and a municipal lot across the street. Just minuted to parkway and LIRR. Asking $439, 000. Taxes $12,000. Nancy Scarola Real Estate, Inc. 516-633-5300 Direct Cell or email nsrehomes@aol.com.

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

MSSNY eNews: August 21, 2014

NYRX
drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 21, 2015
Volume 15, Number 32

Dear Colleagues:

This past week, POLITICO reported that non-profit insurers are losing money on the Medicare Advantage products under the ACA.  Essentially, the rising cost of operations, the transitional reinsurance fee and health insurance industry fee have been blamed for company losses.  Whereas national for-profit insurers can better spread their varying regional costs of operations, constraints by the federal government on non-profit regional plans reportedly reduce these regional plans’ abilities to mitigate their losses.  These regional plans are vital as they stimulate competition in regional marketplaces.

Ironically, this summer, we have learned of three for-profit insurers (Anthem, Aetna and Centene) seeking to make acquisitions which will reduce the number of competitors in many markets.  These endeavors to consolidate by national for-profit insurers flies in the face of the ACA endeavor to promote competition.  Clearly, the attempts will test the Department of Justice in regards to upholding and interpreting anti-trust laws.

These merger and buy-out attempts come in the wake of studies that highlight just how anti-competitive the markets really are.  The December 2014 GAO Report on markets revealed that in many states, 80% of the insurance products were controlled by three insurers [GAO, Private Health Insurance, 2014].  The AMA’s 2014 study found in 41% of the metro markets studied, one insurer controlled over 50% of market [AMA, Competition in Health Insurance, 2014].

The challenges faced by the non-profit insurers in regional markets are not trivial.  Given the efforts of for-profit companies to consolidate and further control healthcare markets, it’s becoming difficult to see non-profit insurers providing a sustainable alternative to for-profit insurer products.  If non-profit insurers want to survive, it seems to me that they must recognize the value of incentivizing physicians to par with their product offerings.  Physicians have no vested interest in supporting and promoting monopsony scenarios being advanced by the for-profit insurers.  The more attractive non-profit products become to physicians, the greater the likelihood that physicians will be able to exercise individual choice and  opt out of for-profit, competition-limiting products that may be deemed by the physician to be unfair to physicians and their patients and move into competition promoting non-profit products.

Perhaps it’s time for us to reconsider a statewide IPA which could align with such non-profit payers in New York.  At the same time, we need to ramp up the call for collective negotiations legislation so as to mitigate the monopsony scenario currently fomenting.

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

Please send your comments to comments@mssny.org


MLMIC


Governor Vetoes Medicaid Managed Care Prior Approval Legislation
Governor Cuomo vetoed legislation (A.7208, Gottfried/S.4893, Hannon) passed by the New York State Legislature that would have strengthened “prescriber prevails” protections in Medicaid managed care when physicians prescribe certain medications to their patients.   In 2012, the Legislature passed a law to assure “prescriber prevails” protection for anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay or deny approval, undermining the intent of the law. The bill was seeking to fix the loopholes of this law.

The Governor’s veto message noted that:

“I remain committed to ensuring that patients receive the prescription medication recommended by their treating physicians. Current law already includes critical member protections such as rights of appeal, external appeal and fair hearing.  I have further directed the Department of Health (DOH) to respond promptly when patients or their treating physicians assert that managed care plans are preventing them from accessing their medications.

However, enacting this bill would have a significant and un-budgeted impact on the Medicaid global cap outside of the State’s budget process. This would necessarily impact other Medicaid services that may need to be reduced to accommodate this unanticipated spending. This bill would also limit managed care plans’ efforts to deter and prevent inappropriate utilization, thereby hindering the State’s ability to effectively manage pharmacy programs.  Accordingly, I am constrained to disapprove this bill.”

The bill had been supported by many patient advocacy groups.  MSSNY issued a statement that noted “We are disappointed that the bill was vetoed.  The legislation resulted from the fact that there are many physicians, most particularly psychiatrists, who have reported situations regarding Medicaid managed care plans inappropriately delaying access for medications needed by their patients.  Consistent with the veto message, we will work with specialty societies to bring these complaints to the Department of Health to address these plan abuses.”

In this regard, physicians who have experienced inappropriate delays or denials from Medicaid managed care plans in the above-listed drug classes are encouraged to share this information with MSSNY’s Division of Governmental Affairs so that we can press DOH to investigate the companies perpetrating these prior approval abuses.


Support Schumer-Crowley Legislation to Increase Residency Slots
All physicians and medical students are urged to contact their respective members of Congress in support of legislation to increase the availability of medical residency opportunities to help to address the physician shortage problem we face.  A customizable template letter can be sent from the MSSNY Grassroots Action Center here.

These efforts are part of the third annual “Save GME Action Week” where medical students from across the country will advocate for GME funding protection and expansion using legislator visits, letters, phone calls, and social media.  Their “ask” is twofold: 1) Maintain current funding for GME; and 2) Support legislation that will expand GME funding sources and the number of residency positions. MSSNY together with AMA strongly supports legislation introduced in Congress, the Resident Physician Shortage Reduction Act of 2015 (H.R. 2124/S. 1148), sponsored by New York’s Representative Joseph Crowley and Senator Charles Schumer, to create 15,000 new residency slots to overcome the outdated cap placed in 1997.  The AMA has also created a designated advocacy page in support of these efforts, entitled www.SaveGME.org.


E-Prescribing Of All Substances Required By March 27, 2016
Physicians and other prescribers are reminded that New York State’s e-prescribing requirements for non-controlled and controlled substances will go into effect on March 27, 2016. The NYS Department of Health’s Bureau of Narcotic Enforcement has provided information to physicians and other prescribers to assist them in their transition to electronic prescribing.   Practitioners should continue their efforts to become compliant with the law, including working with their software vendors to implement the additional security requirements needed for e-prescribing of controlled substances (EPCS), and registering their certified software applications with the Bureau of Narcotic Enforcement.   According to state officials, over 22,000 prescribers have registered their systems with DOH.

For physicians who prescribe controlled substances, there are additional steps to complete in order to electronically prescribe controlled substances.  These include the following:

  • First, the software you currently use must meet all the federal security requirements for EPCS, which can be found on the Drug Enforcement Agency’s (DEA) web page. http://www.deadiversion.usdoj.gov/ecomm/e_rx/

Note that federal security requirements include a third party audit or DEA certification of the software.

  • Second, you must complete the identity proofing process as defined in the federal requirements.
  • Third, you must obtain a two-factor authentication as defined in the federal requirements.
  • Fourth, you must register your DEA certified EPCS software with the Bureau of Narcotic Enforcement (BNE). Registration instructions are included in the FAQs.

A copy of the BNE’s Frequently Asked Questions (FAQs) can be found here.

EPCS systems must be registered through the ROPES system.  ROPES stands for: Registration for Official Prescriptions and E-Prescribing Systems. To access ROPES, use the following steps:

  • Login to the Health Commerce System (HCS) at https://commerce.health.state.ny.us
  • Under “My Content” click on “All Applications”
  •  Click on “R”
  •  Scroll down to ROPES and double click to open the application. You may also click on the “+” sign to add the application “ROPES” under “My Applications” on the left side of the screen.

EPCS became permissible in New York State and over 90% of the pharmacies can now accept e-prescribing for controlled substances, according to officials from BNE.

DrFirst and MSSNY have partnered to bring MSSNY members the industry’s leading e-prescribing solution at a special discounted price. Information on this program can be found here.

There are additional venders that now have software available to e-prescribe both non-controlled and controlled substances and information on these can be found here.

There will be a waiver process for those physicians who experience technological or financial issues, however, DOH has not yet released this process, but it is expected to do so before January 1. The waiver process will be electronic.   Waivers will be provided for a facility, a large medical practice or an individual physician. The law provides that physicians may apply for a waiver of this e-prescribing requirement as a result of a) economic hardship b) technological limitations that are not reasonably within the control of the physician, or c) other exceptional circumstance.  DOH has indicated that more information on the waiver process will be available shortly.

E-prescribing of non-controlled substances is also required under the law; however, registering of this system with the state is not necessary.

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 until March 27, 2016.

Information regarding e-prescribing may be accessed at the following links:

http://www.health.ny.gov/professionals/narcotic/electronic_prescribing/

http://www.op.nysed.gov/prof/pharm/pharmelectrans.htm 


AMA Foundation Presents MSSNY/Dr. Duane and Joyce Cady Scholarships
This week, the AMA Foundation presented 27  Physicians of Tomorrow scholarships, including the MSSNY/Dr. Duane and Joyce Cady Honor fund, which will provide $10,000 scholarships to fourth-year medical students. “It was a dream come true,” said Duane M. Cady, MD, the namesake of the New York honor fund and scholarships. “I only wish we could do more, especially after seeing the financial needs of the students.”

Visit the AMA Foundation website next week to view the recipient listing and biographies and learn more about the 16 honor funds.

The AMA Foundation has made it a priority to assist medical students in handling the rising cost of medical education. The Physicians of Tomorrow Awards were created in 2004 to provide financial assistance to medical students facing spiraling medical school debt. On average, medical students in the U.S. graduate with a debt load of nearly $162,000. A large debt burden may deter many from practicing in underserved areas of the country or practicing primary care medicine. To date, over 1 million has been granted to exceptional medical students across the nation.


Insurers, PBMs Consider Whether To Cover Female Libido Treatment
Bloomberg News (8/20, Edney) reports that following FDA approval, “health insurers are grappling with the question of whether to cover” Sprout Pharmaceuticals’ Addyi (flibanserin), which treats low libido in women but will have a “prominent warning label for serious side effects.”  Anthem Inc. announced Wednesday that it would cover the drug in many cases, while Cigna Corp. and Aetna Inc. are still working on their policies. PBMs Express Scripts Holding Co. and CVS Health Corp. say they are in the process of evaluating the drug.

USA Today (8/20, Ungar) reports that “it’s still unclear whether and how insurers will cover” the new treatment. Sprout Pharmaceuticals CEO Cindy Whitehead says she expects “parity coverage” from insurers between Addyi and erectile dysfunction drugs, adding that out-of-pocket costs should be similar as well. Analysts note that while PBMs are “aggressively narrowing formularies,” there could be a public outcry if insurers and employers decline to cover the drug, especially if male sexual health treatments are covered. 


STEPS Forward Initiative to Help Physicians Combat Burnout
The problem of burnout and caregiver fatigue among physicians is real and immediate. In fact, research shows that the rates of overall burnout extend to about 40 percent of U.S. physicians, more than 10 percentage points higher than the general population. In response, the AMA has created a program aimed at successfully preventing burnout and promoting well-being for medical professionals.

AMA STEPS Forward, the online practice transformation series launched last June, is offering new online modules that help physicians learn their risk factors for burnout and adopt real-life strategies to reignite professional fulfillment and resilience.


Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline. For other revisions, please refer to the New Program Changes (supersedes all other document references) bullet on the website


Members Only: Your Patients Can Save Up to 75% on Prescriptions
With the rising cost of generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!


August 26th Webinar on The Veterans Choice Program
Hear from leading Veterans Administration officials on new community-based care options, collectively referred to as the Veterans’ Choice Program, for VA beneficiaries in an AMA-hosted Webinar on August 26 from 7pm-8pm.  The AMA successfully advocated for these options to be included in the Veterans Choice and Accountability Act of 2014 to help address staffing shortages at the VA that were uncovered during last year’s scandal.

By explaining how non-VA providers can sign-up to deliver care through the Veterans Choice Program, this webinar will explain how the VA is relying on private practitioners as a short-term solution to delivery problems and workforce shortages.  Participants will understand the conditions of participation and learn how to troubleshoot claims processing issues and payment delays.  The webinar will also dispel common misconceptions about the Choice Program and the presenters will conclude with an assessment of ongoing policy challenges.  Physicians can register for the webinar here.


From Workers Compensation Re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions.  We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!

Please join us for our Fall 2015 District Dialogue Session.  This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014.  The Board plans to provide those who attend with:

  • The latest update on BPR initiatives.
  • Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.

We hope you join us at one of our District Offices.  The locations, dates and times are as follows:

  • Hauppauge
    9/1/15, 12-1 PM
    220 East Rabro Drive, Suite 100
    Hauppauge, NY 11788
    Room 116-H
  • Queens
    9/2/15, 12-1 PM
    168-46 91st Ave
    Jamaica, NY 11432
    3rd Floor, Room 325
  • White Plains
    9/3/15, 12-1 PM
    75 S Broadway
    White Plains, NY 10601
    Waiting Room
  • Buffalo
    9/8/15, 12-1 PM
    Ellicott Square Building
    295 Main Street
    Buffalo, NY 14203
    Suite 400, Room 438
  • Rochester
    9/9/15, 12-1 PM
    130 Main Street West
    Rochester, NY 14614
    Basement Conference Room
  • Albany
    9/15/15, 12-1 PM
    100 Broadway
    Menands, NY 12204
    Room 518A & 518B
  • Syracuse
    9/16/15, 12-1 PM
    935 James St
    Syracuse, NY 13203
    1st Floor-General Assembly
  • Binghamton
    9/17/15, 12-1 PM
    State Office Building
    44 Hawley Street
    Binghamton, NY 13901
    18th Floor-Warren Anderson Community Room
  • Brooklyn
    9/22/15, 12-1 PM
    111 Livingston Street
    Brooklyn, NY 11201
    22nd Floor, Room 1917
  • Manhattan
    9/23/15, 12-1 PM
    215 West 125th Street
    New York, NY 10027
    Room 511

The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact Notifications@wcb.ny.gov if you need assistance with subscribing.


 

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Near Rochester, NY- Very active and established practice grossing $1,000,000+ on 4 days per week. Income after expenses averages $550-650K+ annually. Fully equipped 2,500 sq. ft. office with 5 exam rooms. Office lease available for extension. This is a

“turn-key opportunity” with excellent staff, fully trained. Physician will stay to introduce new practitioner to patients. Contact: Gary N. Wiessen at 631-281-2810 Website: buysellpractices.com or email: gary@buysellpractices.com  All inquiries considered strictly confidential. 


HOME FOR SALE – 500+ ft. of Lighted Cascading Waterfalls
Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914


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CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

Aug. 14, 2015 – Join Independent Practice Task Force


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lgTwitter_logo_blue1
August 14, 2015
Volume 15, Number 31

Dear Colleagues:

At the 2015 House of Delegates of the Medical Society of the State of New York, Resolution 210 was passed calling for the creation of a Task Force on Independent Practice. The purpose of the taskforce is two-fold. First, the Taskforce would explore viable options for independent physicians to collaborate and create practice models to achieve the goals of “diversity of service, economy of scale and collective negotiations.” Second, consult experts and examine successful independent practice models in NY and elsewhere that will facilitate the preservation of independent practice in the State of New York. We need your help!

I am looking to assemble the MSSNY team to tackle this work. This calls for physicians who have developed innovative business models of private practice as well as those who have working knowledge of practice models that can accomplish the goals of the committee. This is NOT a committee for those who want to learn on the job. Rather, it is a team of individuals who have working experience both at the individual practice level establishing new medical business ventures as well as those who have expertise through academic, business and health policy endeavors.

Is your practice unique in what it offers? Have you created an IPA? Have you written a master’s thesis on collective negotiations and messenger model negotiations? Are you a physician offering concierge services or a telemedicine based practice? Are you a physician with a law degree or an MBA that has innovated healthcare delivery for your practice in a non-traditional manner or in an innovatively thriving traditional practice? This taskforce can use your skills.

Please contact Eunice Skelly at MSSNY (eskelly@mssny.org) with a short bio and letter expressing your interest, expertise and what you intend to bring to the taskforce to advance the mission of the project. I will be looking for diversity of practice location as well as types of innovations that may contribute to a robust and comprehensive report and plan of action for preserving independent practice in New York.

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

Please send your comments to comments@mssny.org


MLMIC


MSSNY Survey Details Physician Concerns with Inadequate Health Insurance Coverage Faced By Patients
Legislators in New York and Washington D.C. must take action to assure that health insurance coverage truly provides patients with coverage for needed care, instead of a limited catastrophic benefit, according to survey results gathered by the Medical Society of the State of New York.

“The increased availability of subsidized health insurance coverage through New York’s Exchange has certainly been a positive development for our patients, but at the same time we find that more and more of our patients are underinsured due to the increasingly inadequate coverage and narrow networks offered by insurers,” said Dr. Joseph Maldonado, President of the Medical Society of the State of New York.

Many patients are surprised that the health insurance policies for which they have paid thousands of dollars per year will not cover many costs of care until they spend thousands of dollars out of pocket first.  MSSNY’s survey found that significant numbers of patients are facing deductibles imposing huge out of pocket costs before health insurers begin to pay for care.  MSSNY’s survey showed that nearly 21% of responding physicians indicated that one ¼ – ½  of their patients faced deductibles of $2,500-$5,000, and that 32% of responding physicians indicated that up to 10-25% of their patients faced deductibles of $2,500-$5,000.  Moreover, nearly 25% of responding physicians indicated that 25 to 50 % of their patients faced deductibles of $1,000-$2,500, and 36% of responding physicians indicated that up to 25% of their patients had deductibles of $1,000-$2,500.

And many physicians report that the networks that insurers offer to patients are increasingly inadequate.  Nearly 14% of responding physicians indicated that their participation contract with an insurer was not renewed in the last three years, while another 22% indicated that in the last three years they were not invited to participate in a product offering with an insurer despite participating in other products offered by that insurer.  At the same, over 45% of responding physicians indicated that they were inappropriately listed as a participating physician on a health insurer’s website in the last year, which could mask an inadequate physician network.

Even as networks shrink, so do our patients’ ability to be treated by physicians outside the network.  Over 33% of responding physicians indicated that the number of patients they treat with out of network coverage has gone down significantly in the last 3 years, while 42% noted that, for those patients who do have out of network coverage, the insurer covers a far less portion of medical portion of medical costs than they did 3 years ago.  The recent enrollment report by the New York State of Health showed that out of network coverage benefits were only available in 11 counties in New York State, and none below the Bear Mountain Bridge, since insurers have refused to offer this coverage in most areas of the State.

MSSNY is urging policymakers to review these findings closely and to make necessary changes to federal and state laws and regulations to assure health insurers offer comprehensive health care coverage as well as comprehensive physician networks.  A significant part of the problem is a provision of the ACA that enables insures to sell health insurance policies that foist up to 40% of the costs of care on patients.  MSSNY also continues to strongly urge the Legislature to enact legislation (S.1846, Hannon/A.3734, Rosenthal) to assure that our patients have the ability to purchase coverage in New York’s Health Insurance Exchange that enables them to be treated by physicians outside the plan’s network.

“What many physicians find particularly difficult to understand is that, while health insurers continue to constrain the scope of their coverage as noted by the survey results, they also continue to request significant increases in the premiums they charge to consumers and businesses,” said Dr. Maldonado.  “We urge that policymakers look closely at the policies being offered by these insurers and assure that these policies will actually provide coverage for the care needed by our patients.”


Two-Midnight Rule Enforcement Delayed Until 2016
CMS officials announced this week that it would continue to delay until the end of the year enforcement of the controversial “two midnight” rule governing short hospital stays so as to coincide with changes to the policy it recently proposed.

The two-midnight rule calls assumes a hospital admission is appropriate if the patient stays past two midnights.  The rule was adopted in response to a spike in situations of patients going into “observation status.”  Physician and hospital associations, however, have strongly opposed the rule, arguing that it undermines clinical judgment.  Implementation of the rule has been delayed numerous times, including as part of the recent SGR repeal bill until September 30.
In July, CMS proposed that the rule be modified to allow physicians to exercise judgment to admit patients for shorter stays on a case-by-case basis.  The proposal also put quality improvement organizations, or QIOs, in charge of initial reviews of the appropriateness of short inpatient hospital stays, rather than Medicare Administrative Contractors.

For more information, read here:


MSSNY Survey: EHR Usage Shows Continued Frustration with EHR Technology
As government increasingly seeks to condition physician payments on the achievement of hard to define cost efficiency and quality targets, it has decreed meaningful use of electronic health records an essential component of demonstrating quality care.

While this technology holds great promise to enhance care delivery, many physicians across New York and across the country have identified numerous obstacles to successfully incorporating EHR technology into their practice workflow, sometimes interfering with the delivery of patient care.

MSSNY’s HIT Committee has prepared a survey to elicit your thoughts on how EHR functionality could be improved including identifying areas on which additional educational programs would provide meaningful value for practicing physicians.

Please take a couple of minutes to provide your insight on these very important topics.

Please click here to take the survey.


Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline. For other revisions, please refer to the New Program Changes (Supersedes all other document references) bullet on the website.


From Workers Compensation re September District Dialogue Sessions
Thank you to all who attended our Summer BPR Roadshows, which took place during our normal Summer District Dialogue Sessions.  We are very fortunate for everyone’s participation and contribution, making our Summer BPR Roadshow a great success!

Please join us for our Fall 2015 District Dialogue Session.  This will be the Board’s fifth District Dialogue Session since we began holding these sessions in September 2014.  The Board plans to provide those who attend with:

  • The latest update on BPR initiatives.
  • Participant Dialogue Session – time for the Board to hear and discuss topics of interest to you.

We hope you join us at one of our District Offices.  The locations, dates and times are as follows:

  • Hauppauge
    9/1/15, 12-1 PM
    220 East Rabro Drive, Suite 100
    Hauppauge, NY 11788
    Room 116-H
  • Queens
    9/2/15, 12-1 PM
    168-46 91st Ave
    Jamaica, NY 11432
    3rd Floor, Room 325
  • White Plains
    9/3/15, 12-1 PM
    75 S Broadway
    White Plains, NY 10601
    Waiting Room
  • Buffalo
    9/8/15, 12-1 PM
    Ellicott Square Building
    295 Main Street
    Buffalo, NY 14203
    Suite 400, Room 438
  • Rochester
    9/9/15, 12-1 PM
    130 Main Street West
    Rochester, NY 14614
    Basement Conference Room
  • Albany
    9/15/15, 12-1 PM
    100 Broadway
    Menands, NY 12204
    Room 518A & 518B
  • Syracuse
    9/16/15, 12-1 PM
    935 James St
    Syracuse, NY 13203
    1st Floor-General Assembly
  • Binghamton
    9/17/15, 12-1 PM
    State Office Building
    44 Hawley Street
    Binghamton, NY 13901
    18th Floor-Warren Anderson Community Room
  • Brooklyn
    9/22/15, 12-1 PM
    111 Livingston Street
    Brooklyn, NY 11201
    22nd Floor, Room 1917
  • Manhattan
    9/23/15, 12-1 PM
    215 West 125th Street
    New York, NY 10027
    Room 511

The Board has recently added a new email subscription topic for you called “District Dialogues”. Please subscribe to the District Dialogues topic in order to receive any information about past, present, or future District Dialogue sessions. (Click “Manage Preferences” at the bottom left of this email > sign in with your email > click “add subscriptions” > select “District Dialogues” under the General category.) Contact Notifications@wcb.ny.gov if you need assistance with subscribing.


Members Only: Your Patients Can Save Up to 75% on Prescription
With the rising cost of both generic and name brand medications, your patients could all use some help these days!  The New York RX Card, MSSNY’s newest Member Benefit, is a 100% Free and 100% confidential point of sale prescription discount card that can save your patients up to 75% on your prescription medications!  It is free to everyone with no minimum nor maximum uses, no age or income requirements, no enrollment or approval process and it is accepted at over 68,000 pharmacies, nationwide!

This card will provide you with Rx medication savings of up to 75% at more than 68,000 pharmacies across the country including CVS/pharmacy, Duane Reade, A&P, Hannaford, Kinney, Kmart, Pathmark, Stop and Shop, Target, Tops, Waldbaums, Walgreens, Walmart, Wegmans, and many more. You can create as many cards as you need. We encourage you to give cards to friends and family members. This card is pre-activated and can be used immediately!

The NYRX Card works on lowest price logic, to guarantee the best prices on medications.  It won’t lower co-pays or replace existing insurance, but in some cases the New York Rx price is even lower than your patients’ co-pay!  It can be used during the deductible periods in Health Savings Accounts and High Deductible Plans, lowering out-of pocket-expense on prescriptions. Medicare Part D recipients can use the card to discount their prescriptions not covered on their plan as well as receive discounts on medications not discounted when in the “donut hole.”

The NYRX Card is pre-activated and ready to go with no personal information taken or given. NYRX will mail as many cards you desire, directly to your office, with display stands. The cards typically are placed at the patient check out area…additionally, some doctors place them at the check in area too. Contact rraia@mssny.org for your cards!

The August 4th edition of The Daily included a Huffington Post blog by Paul Alexander (“Is New York’s Education Department Making the Doctor Shortage Worse?”) that reported erroneous information about the New York State Education Department (NYSED)’s policy regarding clerkships for international medical students.  MSSNY spoke to Steve Boese, Executive Secretary of the Board for Medicine at the NYSED, who said the information in the Huffington Post blog is incorrect and that no prohibition on clerkships has been put in place.


Clarifying Questions & Answers Re ICD-10 Flexibilities 

 Question 1:

When will the ICD-10 Ombudsman be in place? 

Answer 1:

The Ombudsman will be in place by October 1, 2015. 

Question 2:

Does the Guidance mean there is a delay in ICD-10 implementation? 

Answer 2:

No.  The CMS/AMA Guidance does not mean there is a delay in the implementation of the ICD-10 code set requirement for Medicare or any other organization.  Medicare claims with a date of service on or after October 1, 2015, will be rejected if they do not contain a valid ICD-10 code.  The Medicare claims processing systems do not have the capability to accept ICD-9 codes for dates of service after September 30, 2015, or accept claims that contain both ICD-9 and ICD-10 codes for any dates of service. Submitters should follow existing procedures for correcting and resubmitting rejected claims. 

Question 3:  

What is a valid ICD-10 code? (Revised 7/31/15)

Answer 3:

All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service.  ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity.  A three-character code is to be used only if it is not further subdivided.   While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.

An example is C81 (Hodgkin’s lymphoma) – which by itself is not a valid code. Examples of valid codes within category C81 contain 5 characters, such as:

C81.00  Nodular lymphocyte predominant Hodgkin lymphoma, unspecified site

C81.03    Nodular lymphocyte predominant Hodgkin lymphoma, intra-abdominal lymph nodes

C81.10    Nodular sclerosis classical Hodgkin lymphoma, unspecified site

C81.90    Hodgkin lymphoma, unspecified, unspecified site

During the 12 month after ICD-10 implementation, using any one of the valid codes for Hodgkin’s lymphoma (C81.00, C81.03, C81.10 or C81.90) would not be cause for an audit under the recently announced flexibilities.

In another example, a patient has a diagnosis of G43.711 (Chronic migraine without aura, intractable, with status migrainosus).  Use of the valid codes G43.701 (Chronic migraine without aura) or G43.719 (Chronic migraine without aura, intractable without status migrainosus) instead of the correct code, G43.711, would not be cause for an audit under the audit flexibilities occurring for 12 months after ICD-10 implementation, since they are all in the same family of codes.

Many people use the terms “billable codes” and “valid codes” interchangeably.   A complete list of the 2016 ICD-10-CM valid codes and code titles is posted on the CMS website at http://www.cms.gov/Medicare/Coding/ICD10/2016-ICD-10-CM-and-GEMs.html. The codes are listed in tabular order (the order found in the ICD-10-CM code book). This list should assist providers who are unsure as to whether an additional 4th, 5th, 6th or 7th character is needed.  Using this free list of valid codes is straightforward.  Providers can practice identifying and using valid codes as part of acknowledgement testing with Medicare, available through September 30, 2015. For more information about acknowledgement testing, contact your Medicare Administrative Contractor, and review the Medicare Learning Network articles on testing, such as SE1501. 

Question 4: What should I do if my claim is rejected? Will I know whether it was rejected because it is not a valid code versus denied due to a lack of specificity required for a NCD or LCD or other claim edit?

Answer 4:

Yes, submitters will know that it was rejected because it was not a valid code versus a denial for lack of specificity required for a NCD or LCD or other claim edit. Submitters should follow existing procedures for correcting and resubmitting rejected claims and issues related to denied claims. 

Question 5:  

What is meant by a family of codes? (Revised 7/31/15) 

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Another example, K50 (Crohn’s disease) has codes within the category that require varying numbers of characters to be valid.  The ICD-10-CM code book clearly provides information on valid codes within this, and other categories.  And if in doubt, providers can check the list of valid 2016 ICD-10-CM codes to determine if all characters have been selected and reported.  Examples of valid codes within category K50 include:

K50.00  Crohn’s disease of small intestine without complications

K50.012 Crohn’s disease of small intestine with intestinal obstruction

K50.90    Crohn’s disease, unspecified, without complications

To include the Crohn’s disease diagnosis on the claim, a valid code must be selected.   If the paid claim were to be selected later for audit, the Guidance makes it clear that the claim would not be denied simply because the wrong code was included, so long as the code was in the same family.  As long as the selected code was within the K50 family, then the audit flexibility applies. 

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations.  (See Question 7 for more information about this).  This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected.  The physician can resubmit the claims with a valid code. 

Question 7:  

National Coverage Determinations (NCD) and Local Coverage Determinations (LCD) often indicate specific diagnosis codes are required.  Does the recent Guidance mean the published NCDs and LCDs will be changed to include families of codes rather than specific codes?

Answer 7:

No.  As stated in the CMS’ Guidance, for 12 months after ICD-10 implementation, Medicare review contractors will not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated medical review or complex medical record review based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family of codes. The Medicare review contractors include the Medicare Administrative Contractors, the Recovery Auditors, the Zone Program Integrity Contractors, and the Supplemental Medical Review Contractor.

As such, the recent Guidance does not change the coding specificity required by the NCDs and LCDs. Coverage policies that currently require a specific diagnosis under ICD-9 will continue to require a specific diagnosis under ICD-10.  It is important to note that these policies will require no greater specificity in ICD-10 than was required in ICD-9, with the exception of laterality, which does not exist in ICD-9.  LCDs and NCDs that contain ICD-10 codes for right side, left side, or bilateral do not allow for unspecified side.  The NCDs and LCDs are publicly available and can be found at http://www.cms.gov/medicare-coverage-database/. 

Question 8:

Are technical component (TC) only and global claims included in this same CMS/AMA guidance because they are paid under the Part B physician fee schedule?

Answer 8:

Yes, all services paid under the Medicare Fee-for-Service Part B physician fee schedule are covered by the guidance.

Question 9:

Do the ICD-10 audit and quality program flexibilities extend to Medicare fee-for-service prior authorization requests?

Answer 9:

No, the audit and quality program flexibilities only pertain to post payment reviews.  ICD-10 codes with the correct level of specificity will be required for prepayment reviews and prior authorization requests. 

MEDICAID

Question 10:  

If a Medicare paid claim is crossed over to Medicaid for a dual-eligible beneficiary, is Medicaid required to pay the claim?     

Answer 10:

State Medicaid programs are required to process submitted claims that include ICD-10 codes for services furnished on or after October 1 in a timely manner.  Claims processing verifies that the individual is eligible, the claimed service is covered, and that all administrative requirements for a Medicaid claim have been met.  If these tests are met, payment can be made, taking into account the amount paid or payable by Medicare.  Consistent with those processes, Medicaid can deny claims based on system edits that indicate that a diagnosis code is not valid.

Question 11:  

Does this added ICD-10 flexibility regarding audits only apply to Medicare?  

Answer 11:   The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule. This Guidance does not apply to claims submitted for beneficiaries with Medicaid coverage, either primary or secondary.

Question 12: 

Will CMS permit state Medicaid agencies to issue interim payments to providers unable to submit a claim using valid, billable ICD-10 codes? 

Answer 12:

Federal matching funding will not be available for provider payments that are not processed through a compliant MMIS and supported by valid, billable ICD-10 codes.

OTHER PAYERS

Question 13: 

Will the commercial payers observe the one-year period of claims payment review leniency for ICD-10 codes that are from the appropriate family of codes?

Answer 13:

The official Guidance only applies to Medicare fee-for-service claims from physician or other practitioner claims billed under the Medicare Fee-for-Service Part B physician fee schedule.  Each commercial payer will have to determine whether it will offer similar audit flexibilities.

CMS has recently agreed to hold listening sessions with physician organizations on two sections of the Medicare Access and CHIP Reauthorization Act (MACRA). The next session will address the alternative payment models provisions in MACRA, and will be held on August 19 from 10:30 am to noon Eastern.  DC-based specialty staff will participate in person from the AMA’s Washington office but we are also arranging a call-in line for participation in both meetings by state medical society staff.  A CMS slide deck laying out the MIPS section of the law along with a set of questions is attached.  We expect to have questions to be addressed at the August 19 meeting soon and will send those out as well.  In order to ensure that we have enough phone lines, we ask that if multiple people from the same state plan to participate in the call, they all gather at the same location and use a single phone line.  The call-in line is 866-740-1260.  The access number is 7897464.


MLN Connects National Provider Call: Countdown to ICD-10

Thursday, August 27; 2:30-4 pm ET

To Register: Visit MLN Connects Event Registration. Space may be limited, register early.

Don’t miss the August 27 MLN Connects Call — five weeks before ICD-10 implementation on October 1, 2015. CMS Acting Administrator Andy Slavitt will be opening the call with a national implementation update. Then, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) will be joining us with coding guidance and tips, along with updates from CMS.

Agenda:

  • National implementation update, CMS Acting Administrator Andy Slavitt
  • Coding guidance, AHA and AHIMA
  • How to get answers to coding questions
  • Claims that span the implementation date
  • Results from acknowledgement and end-to-end testing weeks
  • Provider resources

Target Audience: Medical coders, physicians, physician office staff, nurses and other non-physician practitioners, provider billing staff, health records staff, vendors, educators, system maintainers, laboratories, skilled nursing facilities, home health agencies, and all Medicare providers.

Continuing education credit may be awarded for participation in certain MLN Connects Calls. Visit the Continuing Education Credit Information web page to learn more.


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Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.


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Alongside architect-designed, year-round, custom, one-of-a-kind home on 5.1 wooded acres; 5-deck levels, 90 min to NYC; Catskill Mts. Tiled in-ground pool with full-service cabana. $489,000.For more info, go to www.buyawaterfall.com. Or call 845-647-3914


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CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

Aug. 7, 2015: Other payers position’s on CMS’ relaxed ICD-10-CM rules


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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August 7, 2015
Volume 15, Number 30

Dear Colleagues:

Earlier this year, the Commonwealth Fund reported the findings of its 2014 Biennial Health Insurance Survey. It subsequently published a brief on the growing trend of Americans purchasing inadequate insurance coverage. The brief notes that the “share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014”.   It further reports that 23 percent of 19-to-64 year-old adults (31 million) had high out-of-pocket costs or deductibles and were as such, underinsured.  This stands in contrast to the 17 million that were previously uninsured who now have insurance (regardless of its adequacy).  The Commonwealth Fund sounds the alarm calling attention to the problem of the underinsured.

This comes as no surprise to New York’s physicians. Many of MSSNY’s members have been sounding this alarm for several years. The numbers of individuals who, prior to the ACA, had no health insurance has decreased.  But the number of those previously insured with higher deductible plans has increased.  This poses a tremendous burden on both patients and physicians.  The Commonwealth Fund brief notes that more such patients are seeing their credit ratings drop, experiencing bankruptcy and incurring credit card debt to pay their deductibles.

Physicians are required by law to make a reasonable effort to collect payment from patients.  We cannot simply write off the physician charges as bad debt.  For the patient who does not meet their high deductible, failure to meet their deductible obligation to their physician threatens future access to care (57% of patients with a high deductible plan reported at least one cost-related access problem).  Many physicians complain to me about their dilemma in trying to render necessary care–despite the patient’s inabilities to meet their deductible–while maintaining viable practices.  For many, opting out of high-deductible plans or opting out of a particular carrier is the only option for their financial viability.

If we truly want to improve access to care for all Americans, we must design health policies that ensure that ALL Americans have access to care.  This means designing and promoting healthcare insurance products with affordable deductibles that encourage patients to seek care and ensure a full cadre of participating physicians to meet their needs.

Failure to address this problem will destroy America’s middle class and shift the demographics of poor health outcomes from America’s poor to America’s middle class.

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

Please send your comments to comments@mssny.org


MLMIC


SIM/SHIP Listening Tour Sessions in NYC, LI and Albany Next Week: This is Your Opportunity to Participate!
The Department of Health is conducting a Listening Tour to receive input on its design and rollout of the State Innovation Model/State Health Innovation Plan (SIM/SHIP) which will facilitate accelerated delivery system transformation to provide better care at lower cost. Several of MSSNY leaders participated in the SIM listening Tour sessions held last month in Buffalo, Rochester and Syracuse. The SIM/SHIP Tour will hold sessions for physician leaders in NYC, LI and Albany next week! This is your opportunity to participate!

This is a very important opportunity for physicians to provide feedback to the Department of Health on the State Innovation Model (SIM) and the various aspects of the Advanced Primary Care Model. In order to ensure that there is input from our members, you are being invited to participate.

The meeting locations are listed below.  If you are interested in participating, please contact Liz Dears at ldears@mssny.org. Due to space limitations registration is required.

NYC Provider Listening Session:

Date:     8/10/15

Time:    10:00 am – noon

Venue:  United Hospital Fund

1411 Broadway, 12th Floor
New York, NY 10018

Long Island Provider Listening Session:

Date:     8/11/15

Time:    10:00 am – noon

Venue: Medical Liability Mutual Insurance Company (MLMIC)

90 Merrick Avenue – 7th Floor
East Meadow, New York 11554

 Albany Provider Listening Session:

Date:    8/12/15

Time:    10 am – noon

Venue:  MSSNY

99 Washington Avenue, Ste 408

Albany, NY 12210 


MSSNY Survey on EHR Usage and Functionality Shows Continued Level of Frustration with EHR technology- Physicians Who Haven’t Yet Done So, Urged to Complete Survey
Preliminary response to MSSNY’s survey on EHR usage and functionality are consistent with results of other surveys which show a level of dissatisfaction with regard to EHR systems.

While 78% of respondents to MSSNY’s survey are using or plan within two years to use EHRs in their practice or at their hospital, 53% stated that they are either disappointed or very disappointed with their EHR. Notably, 38% of the respondents stated that their EHRs cannot generate routine reports to help manage their patient population, like diabetics, hypertension or ad hoc reports like finding patients due for a flu shot and 29% replied that their EHRs do not support meaningful use 2 or provide guidance on how to achieve MU-2. 56% responded that their EHR did not have prompts to notify them of gaps in patient care. Of the 45% of physicians who stated that they were currently participating in pay for performance (P4P) programs that require reporting from their EHRs, 32% stated that their EHR did not give adequate support to collect data to support their P4P program.

Many stated that they or their staff either manually aggregated the data or purchased additional software to do so. 75% of the respondents did indicate that they were e-prescribing either non-controlled substances only (46%) or both non-controlled and controlled substances (29%). Of those who were not e-scribing, a majority (66%) indicated that the delay in the implementation of the law was the primary reason why they were not yet e-scribing. With regard to educational programming, 46% of respondents stated that they would like more information on three topics: the Delivery System Reform Incentive Program (DSRIP) and how it will affect my practice;  the State Health Innovations Plan and how will it affect my practice; and how to get the most out of the data in your EHR. Other educational programs thought to be of value to respondents included: Value Based Purchasing; What is It and how can physicians position themselves to maximize payment (40%) and Practice transformation; what does this accomplish for the typical physician practice (33%).

Physicians are encouraged, if they haven’t yet done so, to complete the survey by clicking here.


Contact Governor Cuomo to Help Assure “Prescriber Prevails” Protections
Physicians are urged to contact the Governor’s office in support of legislation (A.7208, Gottfried/S.4893, Hannon) that would strengthen “prescriber prevails” protections in Medicaid managed care.  The bill passed the Assembly and Senate before the end of Session, and was just sent to the Governor.

The bill would reduce the hassles physicians are experiencing in trying to assure their patients insured by MMC plans can receive necessary anti-depressant, anti-psychotic, anti-rejection, epilepsy, seizure, endocrine, hematologist and immunologic medications.  In 2012, the Legislature passed a law to assure “prescriber prevails” protection for these drug classes similar to the Medicaid fee for service program, but a quirk in the law has given MMC plans the ability to unfairly delay approval, undermining the intent of the law.  This legislation would help to assure patients can receive these medications with a minimum of hassles.

The Governor has until next Friday, August 14, to act on the bill, so contacts must be made in the next week. A letter can be sent from the MSSNY Grassroots site here or a call can be made to 518-362-8946.


Legionnaires’ Outbreak Has Infected 100, Killed 10
As of Thursday, the Legionnaires’ disease outbreak in New York City has sickened at least 100 individuals. Ninety-two people have been hospitalized and 48 have been treated for the disease and discharged, according to the city’s Department of Health and Mental Hygiene. New York City Health Commissioner Dr. Mary T. Bassett issued a directive Thursday calling for all New York City buildings with water-cooling towers to be accessed and disinfected within the next two weeks. Today, Mayor Bill de Blasio is expected to provide details of a legislative plan he announced this week that is meant to tighten regulation of the cooling towers.


CMS Revised Guidelines Regarding ICD-10 Flexibilities
CMS has revised their FAQs on ICD 10 coding, which are consistent with the original announcement regarding flexibility when the right “family of codes” are submitted. Revisions were made to questions 3 and 5. We are also working with CMS to develop a version of the FAQs that is specifically geared for physicians (attached document is aimed at multiple audiences—Medicare contractors, CMS regional offices) and to be sure that a teleconference planned for late August reflects the initial joint announcement issued on July 6.


ICD-10 News from Non-Medicare Payers
Regina McNally, VP of Socio-Med, has asked non-Medicare payers their view of the AMA’s and CMS’ “relaxed rules” regarding the one-year grace period while physicians transition to full ICD-10 implementation. The following are the non-Medicare payers responses received to date:

  • Aetna: here for Aetna guidelines
  • Cigna: Click here for Cigna guidelines
  • Excellus: “There has been no official decision or discussion on this matter to date.  I suspect we will be following CMS.”
  • HealthPlus/Amerigroup: HealthPlus is evaluating CMS’s guidance for Medicare Part B and its applicability/impact to Medicaid. Consequently, we are awaiting additional guidance from CMS, as to how the agency defines “family” of codes and any guidance specific to Medicaid and Medicare Advantage.  CMS indicated additional guidance is to be forthcoming.
  • Magna Care: http://www.magnacare.com/icd/icd.aspx
  • Medicaid: We are working with CMS and are being advised that they will be issuing guidance to state Medicaid agencies sometime next week.  If you have received or seen anything from CMS it would be great if you could share.  I’ll continue to monitor from our end.
  • MVP: posts its approach and guidelines towards the ICD-10 transition online.  Here is the link. https://www.mvphealthcare.com/provider/ICD-10_updates_and_faqs.html
  • Oscar: We are fairly confident that we will go by this policy for ICD-10: Claims with date of service after 10/1 must have ICD-10 or they will be  Claims received after 10/1 but with date of service before 10/1 can be in ICD-9. For your questions related to a grace period for mis-coded claims, this isn’t a decision that’s been finalized. My sense is that giving providers 365 days to correct a claim is probably too long. We’ll likely stick with our current policy which allows providers to submit an adjusted claim in X number of days after getting a claim decision. X being the number of days a provider has to submit an initial claim. So if a provider has 120 days to submit an initial claim, they’ll have 120 days after getting a claim decision from us to submit an adjusted claim if they feel they made a mistake.
  • SEIU 1199: “For outpatient claims, the 1199SEIU Benefit Funds will deny claims with dates of service on or after October 1, 2015 that is billed with ICD-9 codes.   We will not deny claims if they are submitted with a valid ICD-10 CM and will not deny claims for proper or specificity coding.  Providers can submit corrected claims within 180 days of denials/payment if needed.  For Inpatient Hospital Claims, 1199SEIU Benefit Funds will expect that hospitals apply specificity coding to assign the appropriate DRGs.  Inpatient claims are subjected to reviews to validate this.”
  • UHC: At this point UnitedHealthcare does not believe that any change in our plans is required. The CMS-AMA guidance is specific to Medicare Part B and to medical record reviews / reporting penalties. Actual claim submission (valid ICD-10 code is required for submission) and claim processing should not change (either with CMS or elsewhere). Also, CMS has not issued any additional or modified requirement to health plans regarding ICD-10 claim processing.

Subsequently, when UHC was asked: if Medicare is primary and the physician used an unspecified code within the Family of ICD-10 and Medicare extended their primary benefit, will UHC extend its secondary benefit involving the Medicare deductible and/or coinsurance?  UHC’s replied as follows:

It would still have to be a valid code—not the family code—for CMS submission.  The code submitted can be unspecified, as unspecified codes are valid codes (it should be said that UnitedHealthcare is aligned with the CMS guidance from a specificity perspective in the sense that we do not have a new edit related to ICD-10 specificity) but again it has to be a valid ICD-10 code.  Below is what CMS states about valid codes:

What is a valid ICD-10 code? (Revised 7/31/15)

Answer 3:

All claims with dates of service of October 1, 2015 or later must be submitted with a valid ICD-10 code; ICD-9 codes will no longer be accepted for these dates of service. ICD-10-CM is composed of codes with 3, 4, 5, 6 or 7 characters. Codes with three characters are included in ICD-10-CM as the heading of a category of codes that may be further subdivided by the use of fourth, fifth, sixth or seventh characters to provide greater specificity. A three-character code is to be used only if it is not further subdivided. While diagnosis coding to the correct level of specificity is the goal for all claims, for 12 months after ICD-10 implementation, if a valid ICD-10 code from the right family (see question 5) is submitted, Medicare will process and not audit valid ICD-10 codes unless such codes fall into the circumstances described in more detail in Questions 6 & 7.

Question 5:

What is meant by a family of codes? (Revised 7/31/15)

Answer 5:

“Family of codes” is the same as the ICD-10 three-character category. Codes within a category are clinically related and provide differences in capturing specific information on the type of condition. For instance, category H25 (Age-related cataract) contains a number of specific codes that capture information on the type of cataract as well as information on the eye involved. Examples include: H25.031 (Anterior subcapsular polar age-related cataract, right eye), which has six characters; H25.22 (Age-related cataract, morgagnian type, left eye), which has five characters; and H25.9 (Unspecified age-related cataract), which has four characters. One must report a valid code and not a category number. In many instances, the code will require more than 3 characters in order to be valid.

Question 6:

Does the recent Guidance mean that no claims will be denied if they are submitted with an ICD-10 code that is not at the maximum level of specificity?

Answer 6:

In certain circumstances, a claim may be denied because the ICD-10 code is not consistent with an applicable policy, such as Local Coverage Determinations or National Coverage Determinations. (See Question 7 for more information about this). This reflects the fact that current automated claims processing edits are not being modified as a result of the guidance.

In addition, the ICD-10 code on a claim must be a valid ICD-10 code. If the submitted code is not recognized as a valid code, the claim will be rejected. The physician can resubmit the claims with a valid code.


Emblem Health Response to 7/31 Enews Article: Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
We [Emblem Health] convened a meeting (in follow-up to my forwarding your email) with representation from our Recovery Unit, Medical Directors and Legal department to ensure that all understand that CMS rescinded the MLN SE 1315 document and that it can no longer be used as grounds for recoveries. (We also confirmed that all of the requests that had been made were within the correct look back periods.) A new communication is being prepared to the providers who received the notices.

Regarding the larger issue of the use of Modifier 25, the joint understanding of the group is that it is necessary as the way for providers to let us know that a separate and distinct Evaluation and Management (E&M) service took place in addition to the diagnostic test or procedure. We agree that both events can take place on the same day and that both events can be payable, but they need to be communicated to us in a way that we can distinguish situations where the test or procedure was the sole reason for the visit from those situations where the test or procedure was performed in addition to a discrete E&M service.  According to our Medical Director, visits for “tests only” take place all the time and use of Modifier 25 is a matter of correct coding, not how medicine is practiced.

Emblem Health is planning an education campaign to let providers know that they need to distinguish stand-alone E&M services by using Modifier 25.

For Nassau and Suffolk Physicians


Adelphi University Accelerated MBA Program for Physicians
The Suffolk County Medical Society (SCMS) has formed a partnership with Adelphi University to offer its physician members (and prospective members) an opportunity to obtain an MBA degree from the Robert B. Willumstad School of Business. All classes will be held at SCMS headquarters.

All coursework is related to healthcare and will help you to run a more cost-effective practice as well as become proficient in business strategies. You’ll also gain the necessary skills to be an effective leader, critical thinker, negotiator and problem solver should you choose to be part of the decision-making process in the future of the healthcare system.

Classes will meet on Thursday evenings at SCMS, 1767 Veterans Memorial Highway in Islandia. The program will consist of 42 credits (14 courses) and is AACSB Accredited. For more information about the program, please contact Maureen Leslie, Assistant Director, at 516-237-8607 or leslie@adelphi.edu.



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Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

July 31, 2015 – Facts v. Perceptions in JAMA’s ACA Study


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lg    Twitter_logo_blue1
July 31, 2015
Volume 15, Number 29


Dear Colleagues:

This week, the Journal of the American Medical Association published the findings of a survey which, among other goals, sought to ascertain the nature of changes in access to care, and the health of patients during the first two enrollment periods of the ACA. In addition, the survey wanted to identify differences for low-income individuals in states that expanded Medicaid versus those that did not.  The authors point out the importance of the survey findings for development of future health policy. Sadly, the survey merely serves to highlight the dangers in failing to follow fundamental evidence-based research principles.  If the results are used as intended by the authors, the astute clinician with good critical appraisal skills will understand how flawed research design leads to flawed health policies.

Flawed Core Design

The development of a clear and answerable question is at the core of study design.  Moreover, the findings must be relevant and applicable to the research subjects and/or to the beneficiaries of the study findings.  The study’s questions, methods and findings all fail the relevancy test. A critical appraiser should reject the conclusions of the authors, especially as they are unsuitable for policy development.  “Perceived” patient access to care does NOT equate to access to care.  The ACA may have given more Americans the ability to purchase health insurance. However, having an insurance card, especially a Medicaid product, does not translate to being able to find a doctor to treat you.

“Insurance card access” says nothing about actual access. Will a newly acquired Medicaid card be equal to, better or worse than the care they may have received without insurance or with a non-Medicaid insurance product?  Are these patients actually accessing doctors?  Does the patient’s perception of the quality of care meet the perceptions of other patients with non-Medicaid insurance products? Questions based on patient perception of these matters are important but they should not be the central drivers of health policy.

Evidence of Access Problems

Policy needs to be grounded in more scientifically valid observations— not patient bias.  However, if the goal is to pander to public perceptions to promote health policy that has other agendas as their drivers, then “perceived” improvements in healthcare or access will suffice.  There is growing evidence that access to care is a problem for patients who have signed onto ACA health insurance products.

We now have the data to study access to care based on claims.  Insurance carriers can certainly provide deep data on complication rates, readmissions, and other outcomes.  If we want to develop sound health policy while assessing the current outcomes of patient care under the ACA, let’s do so based on evidence extracted from well-designed studies that are truly relevant to meaningful health policy development.

Perception of care is not delivered medical care. Let’s begin the future with the facts.

JAMA study

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

Please send your comments to comments@mssny.org


MLMIC


Please Take Just a Few Minutes to Complete our Health Insurance Hassles Survey
If you have not already, we urge you to take the opportunity to complete our latest health insurance hassles survey.  To complete the survey, click here.   It should take no more than just a few minutes.  Some of the initial findings of our survey include:

  • Many physicians see patient access to Out of Network coverage shrinking. 33% of the respondents indicated that they treat far fewer patients with out of network coverage than they did 3 years ago, and over 40% indicated that their patients’ OON insurance cover far less of a patients’ medical costs than it did 3 years ago
  • Health plan online participating provider lists are often inaccurate. 45% of the respondents indicated that they were erroneously listed as a participating provider on a health insurer’s website
  • Payments by Exchange plans are poor. Over 75% of the respondents indicated that Exchange plans paid them less than other commercial insurance products, with over 50% noting that the payments were “significantly lower” than payments for other plans offered by that insurer.
  • Health plans are shrinking their networks. Over ¼ of the respondents noted that there were not asked to participate in a new health insurance products offered by a plan with which they participated, with the overwhelming number of respondents noting that the reason was because the plan wanted to offer a “narrow network”.
  • Significant numbers of patients now have hefty deductibles. Nearly 20% of the respondents noted that patients with deductibles of $5,000 or greater comprised 10-25% of their practice, while 32% noted patients with deductibles between $2,500 and $5,000 comprised another 10-25% of their practice; and nearly 40% noted that patients with deductibles between $1,000 and $2,500 comprised another 10-25% of their practice.

These surveys help us to fully understand physician concerns with the contracting process between physicians and these health insurers. The findings also assist MSSNY’s advocacy efforts in the media and with policymakers to support fair contracting, comprehensive health insurer networks and comprehensive out of network coverage.

However, we need a representative cohort of physicians to respond to this survey is we are to be successful in advocating on yours and your patients’ behalf.  Please take just a few minutes to share your perspective.


United Healthcare and In-Network Labs
Effective September 1, 2015, UHC will require its network physicians and other qualified healthcare professionals in NYS to refer to or use network laboratories and pathologists for UHC Oxford NY members.  Any questions? Call United Healthcare Oxford network Laboratory Services Manager, Catherine Schaal at 631-584-0152.


55 Million Enrolled in Medicare; 3.3 Million in New York
55 million Americans are now covered by Medicare, according to a press release issued by CMS this week recognizing the 50th anniversary of Medicare and Medicaid.   The press release noted that there are over 3.3 million New Yorkers enrolled in Medicare, with over 2 million enrolled in traditional Medicare, and 1.25 million enrolled in Medicare Advantage plan.  Moreover, over 2.5 million New Yorkers have prescription drug coverage through Medicare, broken down between nearly 1.4 million enrolled in a Part D plan, and over 1.1 million enrolled in a Medicare Advantage plan with drug coverage. 


Over 2 million New Yorkers Enroll in Exchange; Nearly 75% is Medicaid
2.1 million New Yorkers enrolled in a health plan via the New York State Health Insurance Exchange, according to data released this week by the New York State of Health..  The data indicated that nearly ¾ of that 2.1 million, 1,568,345, were enrolled in Medicaid, with 159,716 enrolled in Child Health Plus, and 415,352 enrolled in commercial health insurance coverage.

The data also showed 9 health insurers enrolled 5% or more of total statewide commercial health insurance enrollees, led by Fidelis Care (20%), Health Republic (19%), Healthfirst (10%) and Empire Blue Cross Blue Shield (10%).  Of great concern, out of network coverage benefits were only available in 11 counties, with 21% of the enrollees in those counties selecting this coverage.   This lack of out of network coverage is exacerbated by the problem many consumers and physicians have reported regarding Exchange plans having inadequate physician networks to meet patient care needs.  Therefore, MSSNY continues to seek legislation (S.1846, Hannon/A.3734, Rosenthal) to require health insurers to offer out of network coverage in New York’s Exchange.

The overwhelming majority (58%) of those who received coverage in the Individual market were enrolled in Silver plans, while 18% enrolled in Bronze plans, 12% enrolled in Platinum plans, 10%  enrolled in Gold plans, and 2% enrolled in Catastrophic plans.  The State also reported that 55% percent of enrollees in the Individual market are in health plans with no annual deductible or deductibles of $600 or less.

While the overwhelming percentage of commercial health insurance coverage enrollment was in the individual market, the data indicated that 3,700 small businesses across New York State had procured coverage through the State Business Marketplace (SBM), providing coverage to nearly 15,000 employees and dependents.   Platinum plans were the most popular plan selected in the SBM representing over one-third of total enrollment. Gold and silver plans had enrollment at 27% and 26%, respectively, and only 13 % of SBM enrollees chose Bronze plans. 


Funding Opportunities Date Extended for Doctors Across New York
The New York State Department of Health, Office of Primary Care and Health Systems Management has made revisions to the Cycle IV Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs Funding Opportunity. The DANY application submission deadline has been extended to Monday, August 31, 2015. Applicants can, and are encouraged to, submit prior to the August 31st deadline.

For other revisions, please refer to the New Program Changes (Supersedes all other document references) bullet on the website.


Legionnaires Disease Outbreak in South Bronx
NYCDOHMH is reporting an outbreak of Legionnaires’ disease in the South Bronx, resulting in two deaths. There have been 31 reported cases since July 10, compared with five confirmed cases during the same period in 2013 and 2014, combined. The rate of Legionnaires’ disease in the Bronx during 2015 has been 3.9 per 100,000 residents, more than twice the rate of the rest of the city. In High Bridge-Morrisania and Hunts Point-Mott Haven, the rate is 8.8 per 100,000. Dr. Jay Varma, New York City’s Department of Health and Mental Hygiene Deputy Commissioner for Disease Control, said what is “unique and important” about the recent outbreak is the “dramatic increase in one specific area.” Officials had noticed an initial uptick in cases last week followed by a large increase over the weekend.


Legislation Introduced in Congress to Address Burdensome Meaningful Use Requirements
This week U.S. Representative Renee Elmers (R-NC) introduced legislation (H.R. 3309, the Further Flexibility in HIT Reporting and Advancing Interoperability Act, or Flex-IT 2 Act) to reduce the overwhelming burdens physicians are facing with complying with federal EHR meaningful use requirements.   A press release by Rep. Ellmers noted that the bill would accomplish the following:

  • Delay Stage 3 Rulemaking until at least 2017, or MIPS final rules or at least 75 percent of doctors and hospitals are successful in meeting Stage 2 requirements.
  • Harmonize reporting requirements (MU, PQRS, IQR) to remove duplicative measurement and streamline requirements from CMS.
  • Institutes a 90-day reporting period for each year, regardless of stage or program experience
  • Encourages interoperability among EHR systems
  • Expands hardship exemptions, as they are very narrowly defined under current regulations

In the press release, Rep. Ellmers made the following statement:

Today’s legislation is key to supplying healthcare providers with flexibility and certainty, as they struggle yet again to meet the Centers for Medicare & Medicaid Services’ (CMS) stringent requirements pertaining to Meaningful Use. This legislation supplies relief by delaying Stage 3 rulemaking until at least 2017 in order to give providers time to breathe and a reprieve from the unfair penalties.”

“Only 19 percent of providers have met Stage 2 attestation requirements—a clear sign that physicians, hospitals and healthcare providers are challenged in meeting CMS’ onerous requirements. Given this basic fact, I’m uncertain why CMS would continue to push forward with a Stage 3 rule. From my conversations with doctors back home, it is clear they are eager for relief.”

“As a nurse, I can speak to the fact that a patients’ health and safety must be put first. This legislation will ensure that hospitals and providers can effectively share information so they can continue to focus their time and attention to caring for patients.”            


Transitioning to ICD-10-CM
This webinar will provide Part B providers with an overview of ICD-10-CM and will assist you with planning for the mandated ICD-10-CM transition. This session will include testing opportunities and transition stages that will help you prepare your office for the upcoming implementation. Please note: As per the CMS IOM Publication 100-09, Chapter 6, Section 30.1.1, National Government Services cannot make determinations about the proper use of codes for the provider. Questions related to ICD-9-CM and ICD-10-CM are handled by the American Hospital Association’s Coding Clinic. Details about this resource are available at http://www.ahacentraloffice.org.

Sessions are available on:


Pulmonary Function Tests and E&M Visits on the Same Day
From Regina McNally, VP, Socio-Med
Back in February 2015, it was brought to the attention of SME that NGS Medicare was seeking recovery action and offset for pulmonary function test done on the same day as an office visit.  In researching this matter, we found that CMS issued a MedLearn article, SE 1315.  This MLN article has no dates.

This old claims examiner (I) believed that the article is not appropriate for standard medical practice.  A Modifier 25 should not be needed to claim ANY diagnostic test (not a procedure) on the same day as a visit.  I asked CMS if they thought it necessary to use a Modifier 25 on the E&M code when an EKG or a lab test is also billed on the same day as a visit.  The author finds the position outlined in the article unnecessary. In addition, just because the RACs do not understand standard medical practice, is no reason for CMS to change the rule regarding a standard medical practice.

Therefore, I alerted CMS Central Office staff and asked that recovery actions for lack of a modifier 25 should be stopped and the article be rescinded.  As of today, July 28, 2015 we have been informed of the following:

Rescinded

SE1315 – Pulmonary Procedures and Evaluation & Management (E&M) Services

If any physician has been the subject of a recovery action on the basis of SE1315, the practice should file an appeal as soon as possible to get their money back if it was refunded or offset. 

Physician Groups Band Together to Address America’s Opioid Crisis
AMA convened task force engages physicians to curb opioid abuse

The AMA Task Force to Reduce Opioid Abuse announced the first of several national recommendations to address this growing epidemic.

The AMA Task Force to Reduce Opioid Abuse  is comprised of 27 physician organizations including the AMA, MSSNY, American Osteopathic Association, 17 specialty and six other state medical societies  as well as the American Dental Association that are committed to identifying the best practices to combat this public health crisis and move swiftly to implement those practices across the country.

“We have joined together as part of this special Task Force because we collectively believe that it is our responsibility to work together to provide a clear road map that will help bring an end to this public health epidemic,” said AMA Board Chair-Elect Patrice A. Harris, M.D., MA. “We are committed to working long-term on a multi-pronged, comprehensive public health approach to end opioid abuse in America.”

Medical Society of the State of New York President Joseph Maldonado, MD, said, “In an effort to reduce prescription diversion and abuse, New York has already taken the lead on this issue. New York’s physicians play a critical role in the effectiveness of the toughest opioid abuse program in the nation since August of 2013.  We are honored to become part of the AMA Task Force to address this epidemic.”

The AMA has long advocated in support of important initiatives aimed at addressing prescription drug abuse and diversion. This includes continued work with the administration and Congress toward developing balanced approaches to end prescription opioid misuse, as well as supporting congressional and state efforts to modernize and fully fund PDMPs.

The new initiative will seek to significantly enhance physicians’ education on safe, effective and evidence-based prescribing. This includes a new resource web page that houses vital information on PDMPs and their effectiveness for physician practices, as well as, a robust national marketing, social and communications campaign to significantly raise awareness of the steps that physicians can take to combat this epidemic and ensure they are aware of all options available to them for appropriate prescribing.


Diagnosing TBI in Your Office
Hospital data reveal that within New York State, over 550 persons per day sustain a brain injury caused by stroke, a Traumatic Brain Injury (TBI) or other factor(s). Actual incidence is higher as the prior numbers reflect only hospital based data; excluded are persons with brain injuries who seek treatment in a clinic, urgent care, or physician’s office, and those with the injury who are not aware of it.  Even a “mild” brain injury can result in lifelong disability, especially if proper treatment is not received.

To promote recognition and treatment of brain injury, the State University of New York at Albany’s School of Public Health produced a webcast, “Recognizing and Treating Mild Brain Injury” for health practitioners, in collaboration with a Federal grant awarded to the New York State Department of Health. The webcast, via “Public Health Live” received rave reviews from the physician, nurse, and nurse practitioner audience.  The program features the one page, evidenced based TBI diagnostic tool, “Acute Concussion Evaluation” (ACE) available free of charge from the Centers for Disease Control and Injury Prevention (CDC) website.

The goal of the program is to increase the number of practitioners able to recognize even the subtle signs of brain injury which may not surface until weeks even months after the initial trauma. That diagnostic ability can save lives and ameliorate the suffering caused by brain injury. The program is easy to access, and lists brain injury related information and materials, including the link to the ACE, all available free of charge. Continuing Medical Education Credits are available as listed below. Practitioners are encouraged to log on to the training at: http://www.albany.edu/sph/cphce/phl_0415.shtml

Continuing Medical Education Contact Hours: The School of Public Health, University at Albany is accredited by the Medical Society of the State of New York (MSSNY) to provide continuing medical education for physicians. The School of Public Health, University at Albany designates this enduring material for a maximum of 1.0 AMA PRA Category 1 Credits TM. Physicians should claim credit commensurate with the extent of their participation in the activity. Continuing education credits will be available until February 2016.

The training was paid in part by a grant from the Health and Human Resources and Services Administration to the NYS Department of Health Grant # H21MC26921.  For more information about the TBI Grant contact, helen.hines@health.ny.gov.



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Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

July 24, 2014 – All in the Family??


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lg    Twitter_logo_blue1
July 24, 2015
Volume 15, Number 28


Dear Colleagues:

Editor’s note: MSSNY President Dr. Maldonado is on vacation. This week’s Enews introduction is written by Michelle A. Leppert, CPC, a senior managing editor for JustCoding.com. And an editor for HCPro publication, Briefings on Coding Compliance Strategies.

Remember those friends and family cell phone plans where you didn’t use minutes if you called people in your circle? You had to pick who you wanted in your group and they had to pick you. It was very confusing trying to figure out who was in the family and who wasn’t.

CMS created the same kind of confusion last week when it basically cut a deal with the American Medical Association (AMA). The AMA, you may recall, has been very vocally opposed to ICD-10 being implemented in any way, shape, or form. To get AMA to cease and desist its defiance, CMS gave AMA something it wanted: no penalties for some coding errors and advanced payments if the technology goes kerflooey.

I can totally understand advancing payments if the system doesn’t work. That’s pretty straightforward. The physician gets paid on time and doesn’t have to worry about going under because of something he or she can’t control. The physicians will have to repay the advanced payment once the system is running smoothly, so they aren’t getting extra money. They just get a hedge against a Y2K meltdown. 

Coding from the Right Family?

The confusing part of the pact is the hold harmless for miscoding. AMA initially wanted physicians to get a pass on coding errors for two years. I’m pretty sure AMA knew that wasn’t going to fly, but when you negotiate, you always start high. In the final deal, CMS stated auditors will not deny a claim “based solely on the specificity of the ICD-10 diagnosis code as long as the physician/practitioner used a valid code from the right family.”

CMS does not, however, define a family of codes. Is it a category of codes, such as S00, superficial injury of head? That could be interesting. S00 has nine subcategories of codes, each with their own subcategories. Or does CMS mean those subcategories, say S00.4, superficial injury of ear? Again, S00.4 includes eight subcategories with their own subcategories.

Maybe CMS considers a family to be the smallest group of subcategories. So under S00, we could go all the way down to S00.46-, insect bite (nonvenomous) of ear as a family. That would give us three codes in the family:

  • 461, insect bite (nonvenomous) of right ear
  • 462, insect bite (nonvenomous) of left ear
  • 469, insect bite (nonvenomous) of unspecified ear

That seems reasonable. The only missing information is the laterality. Not a huge deal, but really the physician should be documenting it. Maybe the coder just couldn’t find it or was in a hurry and defaulted to unspecified.

Let’s consider open wounds of the eyelid and periocular area (S01.1). This is a subcategory under open wound of the head (S01). We’ve already narrowed it down to a specific area. The question becomes, is everything under S01.1- a family? I hope not. Here’s why. The first subcategory under S01.1- is S01.10- (unspecified open wound of eyelid and periocular area). S01.10- further specifies laterality:

  • 101-, unspecified open wound of right eyelid and periocular area
  • 102-, unspecified open wound of left eyelid and periocular area
  • 109-, unspecified open wound of unspecified eyelid and periocular area

That last one’s a killer because it tells you nothing. No wound type, no laterality.

Subsequent Encounters

Additional subcategories under S01.1- specify the type of wound:

  • Laceration with (S01.12-) and without foreign body (S01.111)
  • Puncture wound with (S01.14-) and without (S01.131) foreign body
  • Open bite (S01.15)

I can see not penalizing someone for failing to reporting the “without foreign body” code instead of requiring coders to query if the physician doesn’t document that no foreign body remained in the wound. The question of with or without foreign body becomes tricky when you start looking at subsequent encounters.

If S01.1- is a family, claims won’t be denied if you report S01.109- instead of S01.132- (puncture wound without foreign body of left eyelid and periocular area). Fractures will be even more confusing, largely because ICD-10 includes so many variations of fracture codes. What about specificity for diseases, such as diabetes? Where do you draw the family line? Is it the type of diabetes? So all codes under E11 (Type 2 diabetes mellitus) are one family?

Or do you go to the first subcategory and say all codes under E11.3- (Type 2 diabetes mellitus with ophthalmic complications) are the same family and therefore we won’t deny the claim if you have any E11.3- code. Maybe CMS goes one step further and really narrows down the family to E11.31- (Type 2 diabetes mellitus with unspecified diabetic retinopathy), which includes two codes:

  • 311, Type 2 diabetes mellitus with unspecified diabetic retinopathy with macular edema
  • 319, Type 2 diabetes mellitus with unspecified diabetic retinopathy without macularedema

We don’t know. I’m not convinced CMS knows at this point.

Something else we don’t know—how does this deal with AMA affect hospitals? CMS and AMA both only reference Part B physician fee schedule claims. What about Part A claims? Is CMS going to extend the same breaks to hospitals? Again, we don’t know.

CMS may have finally gotten the AMA on board with ICD-10, but it sure created a lot of additional confusion along the way.

Joseph Maldonado, M.D, MSc, MBA, DipEBHC
MSSNY President
Please send your comments to comments@mssny.org


MLMIC



Reminder: MSSNY General Counsel Develops Template Forms for Physicians To Comply With Out of Network Law Required Disclosures
As a reminder, MSSNY’s General Counsel Donald Moy, Esq. has developed model template disclosure forms that physicians can use in their practices to comply with the new “surprise medical bill” law which took effect on April 1, available from the MSSNY website (Members Only) here. These new requirements include:

                             Network and Hospital Affiliations

All physicians must provide to patients or prospective patients in writing or on the physicians’ website prior to the provision of non-emergency services:

  • The health care plans with which the provider participates; and
  • The hospitals with which the health care professional is affiliated

For the model form physicians can use in their practice, click here.

Model Form #1

In addition, this participation/affiliation information must be provided verbally at the time an appointment is scheduled.

                                               Fee Disclosure

Physicians who do not participate in the network of a patient’s or prospective patient’s health care plan must:

  • Prior to the provision of non-emergency services, inform the patient or prospective patient that the amount or estimated amount the patient will be billed for health care services is available upon request;
  • Upon receipt of a patient or prospective patient’s request, the amount or the estimated amount (in writing) the patient will be billed for health care services, absent unforeseen medical circumstances that may arise when the health care services are provided

For the model forms physicians can use in their practice, click here, Model Forms #2-A, 2-B and 3

Other Health Care Providers Involved in Providing Patient Care

Allphysicians who refer or coordinate services for patients with another provider must provide to their patients the name, practice name, mailing address, and telephone number of any health care provider scheduled to perform anesthesiology, laboratory, pathology; radiology; or assistant surgeon services, in connection with care to be provided

  • in the physician’s office;
  • as coordinated by the physician; or
  • as referred by the physician.

For the model forms physicians can use in their practice, click here, Model Form, #4

Other Physicians Involved in Hospital Care

At the time of a patient’s pre-admission testing, registration or admission for scheduled hospital admission or outpatient hospital services, all physicians must provide their patients with the name, practice name, mailing address and telephone number of any other physician whose services will be arranged by the physician and are scheduled at the time non-emergency services are scheduled.

For the model forms physicians can use in their practice, click here, Model Form #5.

There are also numerous other provisions incorporated into this new law which took effect this past April 1.  For a summary click here.


Residents Salary & Debt Report 2015: Are Residents Happy?
Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program. In 2015, the average resident salary—$55,400—was a slight increase over that reported in Medscape’s 2014 Residents Salary & Debt Report ($55,300). The figure averages higher earnings in such specialties as critical care and oncology and lower earnings in other specialties, such as primary care. Some 68% of residents have a considerable amount of medical school debt (exclusive of any other debt): $50,000 or more. Well over one third (37%) of residents have over $200,000 in debt, and over one fifth (22%) have $100,000-$200,000. Another 9% have $50,000-$99,999, and 10% have less than $50,000. A fortunate 22% of residents have no debt.

Nearly two thirds (62%) of the residents we surveyed reported that they considered their compensation fair. This is higher than what was reported by practicing physicians; almost one half (47%) of primary care physicians feel fairly compensated, and 50% of specialists feel fairly compensated. Medscape surveyed more than 1700 residents in 24 specialties to take part in an online survey from May 14, 2015, through June 22, 2015. All participants were enrolled in a US medical resident program.


Missed the Meaningful Use Town Hall Meeting? Watch a Re-Broadcast
This week the AMA hosted a special national “town hall” meeting in Atlanta to highlight physician concerns with electronic health record systems (EHRs).  The forum gave physicians an opportunity, both in person and via Twitter, to express concerns with their efforts, often futile, to achieve meaningful use of EHR systems in order to avoid Medicare payment penalties.  In many cases, physician speakers noted that they had been “early adopters of EHR technology, yet still could not achieve meaningful use Stage 2, and had simply chosen to accept penalties in lieu of the interference they were facing in trying to provide needed patient care.  Moreover, physicians shared frustrations about the failure of EHR companies to assure that medical record systems become interoperable to better enable the sharing of treatment information when physicians treat the same patient.  To watch a re-broadcast of the “Town Hall” event, click here: http://live.breaktheredtape.org/.  To read more about this event, click here.


Your New Video – Countdown to ICD-10: 10 Facts about ICD-10
The Centers for Medicare & Medicaid Services (CMS) has released an exciting new video to help ease your transition as we count down to ICD-10 implementation. This animated video highlights ten facts of what to expect during the ICD-10 transition.

The following videos are currently available for viewing on CMS’s YouTube channel:

The 10/1/2015 implementation date is fast approaching and these videos will provide an overview of ICD-10 as well as explain the benefits of the new code set. It will also provide implementation guidance and coding examples. We hope you find these videos to be a valuable asset as we count down to ICD-10.


National Government Services Needs YOUR Help! Take Their Survey!
We know how busy you are but we urgently need our customers’ perspective. We are counting on you and your staff to complete the Medicare Satisfaction Indicator (MSI) and website ForeSee surveys. It takes time, but the benefit of taking these two surveys will help you as a Medicare Provider and us as a Medicare Contractor determine how we are performing.  Are you happy with us?  We hope you are, but if not, we need to know that too!  Good, bad, or indifferent, your feedback is a necessity!

Both surveys are available on their website at www.NGSMedicare.com.  The MSI survey banner is displayed on the home page.  For the website ForeSee survey, you are randomly chosen to take it, so whenever you do get that option, please click “yes, I’ll give feedback.”  As we work with your suggestions, you will be glad you took the 5-10 minutes to complete the survey.

This link will take you to the MSI survey for Part A and Part B providers.

Link to CMS MAC MSI Survey


What You Should Know about MEDICARE/MEDICAID Dual Eligibles
The following is provided as an informational reminder from Socio-Med VP Regina McNally:

As you should know, effective July 1, 2015 NYS Medicaid is no longer paying the 20% of the 20% coinsurance from the Medicare claim for Medicare/Medicaid dual eligible patients.  The NYS budget did not include funding to maintain this benefit from the NYS Medicaid Program. The final budget, accepts in part, the Executive’s proposal to limit Medicaid payments for dual eligibles’ Medicare Part B coinsurance amounts so that the total Medicare/Medicaid payment to the provider does not exceed the amount that the provider would have received for a Medicaid-only patient. The final budget accepts this cut with respect to dual eligibles in fee-for-service Medicare, but rejects it for dual eligible beneficiaries who are enrolled in Medicare Advantage plans. This cut took effect on July 1, 2015.

The June 2015 Medicaid Update on this matter reads as follows:

Effective July 1, 2015 a change to New York State Social Services Law adjusts Medicare Part B coinsurances reimbursement methodology for practitioner claims: Medicaid presently pays practitioners the full Medicare Part B annual deductible and partial Medicare Part B coinsurance amounts (20 percent of the Part B coinsurance) for Medicaid covered services provided to Medicare/Medicaid dually eligible recipients. Pursuant to recent changes to Social Services Law, New York State Medicaid has revised the reimbursement methodology for practitioner claims effective July 1, 2015. 

Beginning July 1, 2015, Medicaid is no longer reimbursing partial Medicare Part B coinsurance amounts. The total Medicare/Medicaid payment to the provider will not exceed the amount that the provider would have received for a Medicaid-only patient. If the Medicare payment is greater than the Medicaid fee, no additional payment will be made.

Note: The Medicare and Medicaid payment (if any) must be accepted as payment in full. Per State regulation 18 NYCRR Section 360- 7.7, a provider of a Medicare Part B benefit cannot seek to recover any Medicare Part B deductible or coinsurance amounts from Medicare/Medicaid Dually Eligible Individuals.

There is no change to the current reimbursement methodology of Medicare Part B coinsurance for the following: Ambulance providers; Psychologists; Article 16 clinics; Article 31 clinics; and Article 32 clinics. Medicaid will continue to reimburse these providers the full Medicare Part B coinsurance.

Reminder: If a patient is dually eligible, private practitioners must bill Medicare prior to billing Medicaid for the Part B co-insurance. Most claims are submitted to Medicare and are automatically crossed over to Medicaid for processing.

If a medical practice is enrolled with a Medicare Managed Care (MMC) (Medicare Part C), when the MMC pays the practice the payment is expected to be considered as payment in full.  The medical practice should review its MMC contract.

Regrettably, this goes back to the federal Balanced Budget Act of 1997.  The BBA included a clause that stated the states no longer had to pay the coinsurance amounts for “dual eligible.”  The BBA was passed at the time when MSSNY had just won the Medicare/Medicare Crossover lawsuit.  Therefore, NYS had decided to continue paying a small portion of the Medicare Coinsurance amount.  However, it just so happens that this year, the state decided to no longer include payment for this in the state budget.  The state will still cover the Medicare Part B deductible, though.

The statute  §1902(n)(3) of the Social Security Act) says that, where the State Medicaid program limits the amount it will pay for deductibles and coinsurance for QMBs, “for the purposes of applying any limitation under title XVIII [Medicare] on the amount that the beneficiary may be billed or charged for the service, the amount of payment made under title XVIII [Medicare] plus the amount of payment (if any) under the State plan [Medicaid] shall be considered to be payment in full for the service…”

Therefore, under Medicare rules, the provider has been paid in full if it receives the normal Medicare payment amount for the service plus any amount that Medicaid pays, even if Medicaid pays nothing.  It doesn’t matter that the provider is not enrolled in Medicaid, billing beyond what Medicare and Medicaid pays would be a violation of Medicare rules.

When treating a dual eligible, there is mandatory assignment for the Medicare claim.  This is not a new rule.

Can a physician who is not enrolled in Medicaid bill a Medicaid recipient for the Medicare deductible?

The answer is no. Under no circumstance can a provider balance bill dual eligible.  The provider needs to enroll in the Medicaid program as a non-participating provider for Medicaid to cover the Medicare deductible. Being enrolled in Medicare, you need to be cautious about not treating dual eligibles in your medical practice. Any patient should not be discriminated against because of the health insurance they have or don’t have.

Since a medical practice should not discriminate against any patient based on the type of payer/insurance/plan by which the patient is covered, a practice can make a business decision to limit the amount of patients it can handle from a particular plan.  So, the practice can say it can’t take any more patients from “X” plan.

Questions Regarding Out of Network Telephone Audits

Question: I am an out of network physician, but a health plan wants to audit me. What are my obligations?

Being out of network, physicians would be non-participating and therefore have NO contract with a health plan. To par or not to par with a health plan must be an individual business decision by any physician/practice.

A physician without a contract with a health plan who is asked to go through an audit process, should tell the health plan that a patient authorization is required before an audit can be conducted.  Without a contract, physicians have no obligation to a health plan but do have a privacy obligation to their patient. If the patient is covered by a health plan, the link is between the health plan and the patient. If the health plan wants the patient’s medical record, the health plan needs to obtain the patient’s authorization for disclosure of his/her medical information by the physician.

Physicians without contract with a health plan have no obligation to the plan.  The physician’s only obligation is to the patient.  Physicians should not leave themselves open to violations of their patients’ privacy.  Without the patient’s authorization to disclose their medical record, the physician has no authority to disclose the information.

Question: What if I have a contract with the plan?

If the health plan takes a negative position and wants the call to proceed without the benefit of recording and the physician has a contract, then the physician would need to make a business decision about the possibility of putting his/her contract at risk of termination.

Question: I am out of network. What if I receive a check from the plan?

When a physician has no contract with a health plan and the health plan inadvertently sends the physician a check, if the physician cashes the check, there could be an implied assignment of benefit whereby the physician is expected to “stand in the shoes of the patient.” If the physician does not want an implied assignment of benefits, the word “VOID” should be written across the face of the check and the check should be returned to the health plan with the instruction to reissue the check to the health plan’s insured/patient.

Question: Can I record a telephone audit?

It would be a good idea and a professional courtesy to inform the auditor that the telephone call will be recorded.  If the health plan representative chooses not to be recorded, then the audit would not need to proceed for a physician who has no contract. 

In reference to recording a telephone audit, the law on this is as follows:

NYS Penal § 250.00 Eavesdropping; definitions of terms.

    The following definitions are applicable to this article:

  1. “Wiretapping” means…   
  2. “Mechanical overhearing of a conversation” means the intentional overhearing or recording of a conversation or discussion, without the consent of at least one party thereto, by a person not present  there at, by means of any instrument, device or equipment…..

                                                                                   –From Regina McNally


Comprehensive Care for Joint Replacement (CCJR) Model Webinar Materials Posted
In follow-up to the July 9, 2015 announcement of the Comprehensive Care for Joint Replacement (CCJR) Model, the CMS Innovation Center hosted two webinars on July 15 and July 16, 2015. These webinars focused on providing an overview of the Model and provided an opportunity for attendees to ask questions.

The materials from these overview webinars are now available on the CCJR Overview webinar page. To access the audio recordings of both webinars, an email address is required. If already registered, please use the same email address used at the time of registration. Additional information on the CCJR Model can be accessed through the CCJR Model web page 


Calling All Amateur Photogs for MSSNY’s Social Media Feeds
We’d like to include more happenings from around the state in our Twitter, Facebook and Instagram feeds. If you’re at an event that you think might be of interest to our followers, please snap a picture with your phone and send to jvecchione@mssny.org with your name.  Be sure to include a caption or some identifying words. If you’re traveling around our beautiful state this summer, send us a photo!



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Doctors Digital Agency
When you understand your practice is an online business, tell us where it hurts.   Whether your website needs a simple refresh or serious surgery, our digital doctors heal what hurts. Doctors Digital Agency will improve your site’s front-end user experience and back-end functionality.  That means more patients, more phone calls, more patient time, more profitability. We use responsive design to build mobile and search-engine friendly custom websites. Leverage electrons!  Visit http://www.doctorsdigital.agency Email: hello@doctorsdigital.agency, or call 786-529-2025. Doctors Digital Agency, Inc. Since 1996.

CALL FOR RATES & INFO. CHRISTINA SOUTHARD: 516-488-6100 ext. 355

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