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.

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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.


 

CLASSIFIED


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. 


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

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
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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.


CLASSIFIED


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. 


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.


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

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
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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.



Classifieds

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
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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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eNews July 17, 2015 – Physicians and “Freebies”


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
asset.find.us.on.facebook.lg    Twitter_logo_blue1
July 17, 2015
Volume 15, Number 27

Dear Colleagues:

This past week, Joe Queenan wrote a column in the Wall Street Journal entitled “Is There a Doctor in the House?”  Mr. Queenan suggests that physicians ought to behave like many other business owners who throw a patient/customer/client a “freebie” once in a while.  He proposes that procedures that an individual undergoes on a regular basis should form the basis for the occasional freebie.  Mr. Queenan initially rejects the notion that major surgical procedures, imaging studies and other infrequent procedures should not be the subject of the freebie but then gives as freebie examples—  nasal endoscopies, acupuncture and physical therapy.  Mr. Queenan’s column is perhaps part tongue-in-cheek humor, but it reflects quite accurately the ignorance of many Americans regarding how much free work physicians do. Perhaps the ignorance is predicated on how he has constructed his view of what constitutes a “freebie.”  This is suggested by a question he raises—“But when you see a physician several times a year, shouldn’t you feel entitled to a freebie every once in a while?”

Americans, both rich and poor, have developed a sense of entitlement.  Programs such as Medicare, Medicaid and now, the ACA, have promoted a sense of entitlement for many Americans regarding healthcare.  They are not just entitled to care.  They are entitled to FREE care.  What Mr. Queenan fails to recognize is that we DO provide free care.  We do so, consciously and unconsciously. After going the extra mile, we often fail to bill for a service.  We merely decided that providing the service was “doing the right thing” and we fail to bill the patient.  Sometimes we are aware of the personal cost to a patient for a co-pay or deductible and we simply fail to bill the service altogether for fear that forgiving the co-pay or deductible will lead to criminal and professional charges.

In my experience, doctors never brag or advertise that they’ve done a good deed.   They just do their mitzvahs— no need to announce it.  In doing so, they risk engendering ingratitude from folks with a sense of entitlement who then expect freebies at every visit rather than every fourth visit.  Most of the time, these “entitled” folks are unaware of the charity work or medical missions their doctors have taken in lieu of a vacation – at personal cost of family time, resources and compensation.

Should we highlight more of our own freebies to our “entitled” patients?  I don’t think so.  We didn’t give the freebie to garner their loyalty or adulation.  We gave them for altruistic reasons, knowing many would not appreciate them but feel they “earned” those freebies.  In fact, I would suggest that some may feel that they are doing us a favor by coming to us and allowing us to bill for the other services which should have been freebies, too.  When Mr. Queenan realized his dry cleaner never threw him a bone, he stopped taking his business to that cleaner, even though, in his own words, “they were consummate professionals.”  Most of us would still remain available to ungrateful and entitled patients.  Others, having provided innumerable silent freebies to countless patients would be happy to simply say to those who feel entitled to another freebie and opt to leave us for greener pastures elsewhere—   “Don’t let the door hit your backside on the way out.”

Mr. Queenan, may I open the door for you as you leave?

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


 

MLMIC



NYSIF Announces Launch of Online Medical Provider Portal
The New York State Insurance Fund recently announced the launch of its new online Medical Provider Portal at www.nysif.com. The new portal will allow registered providers and third party billers to retrieve claims payment information regarding their workers’ compensation patients.

Once a provider registers at nysif.com, he or she will be able to self-serve and obtain access to an explanation of benefits (EOB), bill payment status (with amount paid), claims covered on an issued check and claim-by-claim pricing and payment accounting.

To register for a medical provider user account, go to www.nysif.com and follow the instructions for registration. Providers will need a copy of their latest check from NYSIF to complete registration.  To safeguard the privileged information of both the medical provider and the claimant, obtaining EOB and bill payment information will now require a log-on before accessing that data.

If a provider uses a third-party billing company, the biller must also register for an account to obtain access to the provider’s information.  Once the vendor completes the registration, NYSIF will send the vendor a unique identifier code that they must share with the provider. Once a medical provider has designated the vendor as an approved third party biller, the biller will have online access to that provider’s medical bill payment information and explanation of benefits. Please note only the medical provider can approve access to the portal for the third party billing company.

Please take a moment to visit nysif.com today and register! 


Fed Up with EHRs? Share Concerns during AMA Town Hall Meeting
This Monday night, July 20, from 7 to 8:30 p.m., the AMA, in conjunction with the Medical Association of Georgia, will be hosting a special town hall meeting in Atlanta to discuss concerns with electronic health record systems (EHRs). The event will be live-streamed so physicians can participate at home and via Twitter with #FixEHR.

Among the national and local leaders who will be a part of the conversation will be Rep. Tom Price, MD, a Republican from Georgia’s 6th District, and AMA President Steven J. Stack, MD.

According to the AMA, physician participation in Stage 2 of meaningful use is less than 10 percent, even though 80 percent of physicians have adopted EHRs. Moving forward with Stage 3 could mean less time with patients, hindrances to practice innovation and costly penalties. Many physicians have complained that government requirements have affected EHR technology so it does not productively synch with physician workflow, such as interfering with face-to-face discussions with patients, requiring physicians to spend too much time performing clerical work and creating new costs that divert resources away from patient care improvements. Meanwhile, the much anticipated benefits of being able to share important patient health care information electronically among providers in different settings have gone unfulfilled.


CCNY Medical School to Welcome First Class in 2016
The City College of New York announced the establishment of the CUNY School of Medicine at City College in partnership with Bronx-based St. Barnabas Hospital, which is part of the SBH Health System. The new Harlem-based medical school, whose first class is scheduled to begin fall 2016, will be an expansion of City College’s Sophie Davis School of Biomedical Education. Established in 1973 on the City College campus, the Sophie Davis School currently offers a unique seven-year BS/MD program that integrates an undergraduate education with the first two years of medical school.

The new medical school on the City College campus builds on the strong record of achievement of the Sophie Davis School of Biomedical Education, whose mission is recruiting underrepresented minorities into medicine, increasing medical care in historically underserved communities and boosting the number of primary care physicians.

City College President Lisa S. Coico said the newly established school would nurture young students to embrace a career focused on caring for their fellow citizens with passion, empathy and respect. “The need for more physicians in many communities in our city, particularly in the communities surrounding City College, remains dire,” she said. “By establishing this resource, City College is both helping to address this critical need and fulfilling a vital community service.” 


CMS Releases Proposed Medicare Payment Rule for 2016
CMS recently released its proposed Medicare Part B payment rule for 2016.  To read the CMS press release highlighting some of most notable aspects of the proposal, click here.  The proposal begins to implement aspects of the Merit-Based Incentive Payment System (MIPS) enacted as part of the SGR repeal legislation as well as making changes to several of the quality reporting initiatives that will in 2019 be consolidated into the MIPS program, including the Physician Quality Reporting System (PQRS), the Physician Value-Based Payment Modifier (Value Modifier), and the Meaningful Use Program.   The SGR repeal proposal also provided for a 0.5% increase in the conversion factor July 1, as well as another 0.5% increase on January 1, 2016.

Among the issues items brought up in the proposal:

  • Establish Medicare fees for two advance care planning services provided to Medicare beneficiaries by physicians and other practitioners. (as referenced in last week’s MSSNY’s e-news);
  • Bringing up to 300 the number of measure reportable under the PQRS program. If an individual practitioner or group practice does not satisfactorily on PQRS quality measures, a 2% negative payment adjustment would apply in 2018;
  • Proposing a methodology to impose a 0.25% reduction in Medicare spending due to reductions in certain misvalued codes, as required by provisions incorporated in prior year’s legislation (the “ABLE” Act enacted in 2014).  CMS noted that it could make further misvalued code changes in the final rule to move closer to the statutory goal of 1% based on public comment.
  • With regard to 2018 Value-Based Modifier payments (which will be based upon 2016 performance), to set the maximum upward adjustment of +4.0 times the adjustment factor (to be determined after the conclusion of the performance period), for groups with ten or more EPs; +2.0 times the adjustment factor, for groups with less than 10 EPs;  as well as to set the potential penalty in 2018 to -4% for groups with ten or more EPs, and -2% for groups with less than 10 EPs.
  • Updating self-referral limitation provisions to establish a new exception to permit payment to physicians for the purpose of employing non-physician practitioners.

MSSNY will be working with the AMA and the federation of medicine to review the rule and to make comments on key components.  Here is a link to the entire 2016 proposed Medicare payment rule.


Telemedicine Companies Popping Up in New York
Pager — a New York-based service that’s looking to revive the practice of house calls by doctors — just raised $14 million in a funding round co-led by Aston Kutcher’s firm Sound Ventures, valuing the company at around $75 million. “Telemedicine” services, in which doctors diagnose and treat patients on the phone and online, have been multiplying lately—like Doctor On Demand, Teladoc, MDLive and HealthTap.

But Pager has spent the past year building a network of physicians and nurses in New York City who, in addition to telemedicine services, can visit your home to treat everything from minor injuries to the flu.

Rates are $25 for telemedicine and $50 for an initial doctor’s visit. Subsequent visits are $200 and reimbursable as out-of-network by some plans. Pager expects to be in-network with several major insurers later this year.  


CMS Proposes Part A/Part B Medicare Bundle for Lower Joint Replacement
CMS has proposed to implement a new Medicare Part A and B virtual bundled payment model –  the “Comprehensive Care for Joint Replacement (CCJR)” model – under which acute care hospitals in certain selected geographic areas will receive retrospective reward payments or face financial liability relating to episodes of care for lower extremity joint replacement (LEJR) or reattachment of a lower extremity.   The initiative is designed to test “whether bundled payments to acute care hospitals for LEJR episodes of care will reduce Medicare expenditures while preserving or enhancing the quality of care for Medicare beneficiaries.”

Under the proposal, the program would be implemented in 75 MSAs across the country, including the New York City and Buffalo areas.  There would be a 5 year performance period, beginning January 1, 2016, and ending December 31, 2020.

Under the model, an episode of care would begin upon admission to a hospital for an LEJR procedure and would end 90 days after the date of discharge.  The episode would include the LEJR procedure, inpatient stay, and all related care covered under Medicare Parts A and B within the 90 days after discharge, including hospital care, post-acute care, and physician services.  While spending under Part A and Part B would continue to be made on a fee for service basis, the acute care hospital that is the site of surgery would be held accountable for spending during the episode of care.  Depending on the hospital’s quality and cost performance during the episode, the hospital would either earn a financial reward or be required to repay Medicare for a portion of the costs.  Penalties would not be imposed the first year of the program, and be phased in beginning Year 2.

According to a CMS webinar describing this proposal this week, only the acute care hospitals where the surgery is performed would be ultimately liable for making repayment in certain circumstances where spending exceeds a certain threshold.  However, of significant concern, the hospital could require others who provide care within this “virtual bundle” to be responsible for up to 50% of full the repayment amount, including up to 25% for any one “collaborator”.

CMS states that this payment structure is designed to “give hospitals an incentive to work with physicians, home health agencies, and nursing facilities” to reduce avoidable hospitalizations and complications.  CMS also states that participants would gain access to data and educational resources to better understand post-acute care and associated spending.”

MSSNY will be working with effected specialty societies and the AMA to respond to this proposal.  Comments are due by September 8.  For more comprehensive information from CMS regarding this proposal, click here.


Is Your Infection Control Certification Up-to-Date?
New York State law requires that all health care providers—including physicians, medical residents and medical students—receive training on infection control and barrier precautions every four years upon renewal of their license.  The Medical Society of the State of New York is approved by the New York State Department of Health to provide Infection Control and Barrier Precautions to all healthcare professionals.  Additionally, MSSNY is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Measures to prevent the transmission of disease in health care settings have evolved over the years and, as such, this state-mandated course, with six elements total, includes the most updated information from the New York Department of Health.  The cost of the course is $50, payable online by credit card.  Upon successful completion of the course work, you will be able to print out your Infection Control Certificate of Completion.  Click here to take the course.


Analysis: ACA Plan Networks Offer Fewer Physicians
Health plans sold through the Affordable Care Act’s exchanges offered consumers access to 34% fewer health care providers than employer-based coverage, according to a new Avalere Health report. Avalere examined the largest rating region in the top five states by 2015 exchange effectuated enrollment: Florida, California, Texas, Georgia, and North Carolina. Compared with employer-sponsored coverage, exchange plans on average had networks with 42% fewer cancer and cardiac specialists, 32% fewer mental health and primary care physicians and 24% fewer hospitals. The study noted that the narrow networks can keep premiums low but often leave consumers with higher out-of-pocket costs. (The Hill)


PV-PQRS Users: Set up Your EIDM Account
CMS transitioned Individuals Authorized Access to CMS Computer Services (IACS) accounts to the Enterprise Identity Management System (EIDM). As of July 13, 2015, an IACS account can no longer be used to access a group or solo practitioner’s Quality and Resource Use Reports (QRURs); instead, an EIDM account will be required to access QRURs at https://portal.cms.gov. Below please find the action you should take as soon as possible in order to set up your EIDM account:

  • If you do not have an IACS or EIDM account, then follow the instructions provided here to sign up for an EIDM account with the correct role.
  • If you have an IACS account that you previously used to access QRURs, then follow the instructions provided here to sign up for an EIDM account. You will be allowed to perform the same tasks using your EIDM account that you were able to perform with your IACS account.
  • If you already have an EIDM account, then follow the instructions provided here to sign up for the correct role in EIDM.

For questions about setting up an EIDM account, please contact the QualityNet Help Desk at:

  • Monday – Friday: 8:00 am – 8:00 pm EST
  • Phone: 1 (866) 288-8912 (TTY 1-877-715-6222)
  • Fax: (888) 329-7377
  • Email: qnetsupport@hcqis.org

Additional information on accessing QRURs is available on the CMS website.

 



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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

ICD10: One Year Fiscal Reprieve!!!!! – July 10, 2015


drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R. Maldonado
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July 10, 2015
Volume 15, Number 26

Dear Colleagues:

This week, we received news that our efforts to get some relief from the onerous outcomes for implementation of ICD-10 in October had met with positive action.  Officials at the CMS announced that for a period of one year, physicians would not incur any penalties or delays in payment as a result of incorrect use of the ICD-10 codes.

Thanks to all of you that assisted us with the efforts advanced by the Big Four (California, Florida, New York and Texas) and the AMA.  After sending the Big Four letter, we had a conference call with CMS representatives who listened to the Presidents of the four state societies as well as others.  We relayed our concerns regarding the onerous nature of implementation at a time when physicians are trying to grapple with other reform efforts.  We explained our reasoning for a two-year grace period during which physicians would have to utilize the ICD-10 codes for billing but would not be penalized for errors in the use of ICD-10 codes.  The rationale and justification seemed to resonate with CMS as we have received a grace period– albeit of one year.

The specifics of the announcement are:

  • For a one year period starting October 1, Medicare claims will not be denied solely on the specificity of the ICD-10 diagnosis codes provided, as long as the physician submitted an ICD-10 code from an appropriate family of codes.  In addition, Medicare claims will not be audited based on the specificity of the diagnosis codes as long as they are from the appropriate family of codes.  This policy will be followed by Medicare Administrative Contractors and Recovery Audit Contractors.
  • To avoid potential problems with mid-year coding changes in CMS quality programs (PQRS, VBM and MU) for the 2015 reporting year, physicians using the appropriate family of diagnosis codes will not be penalized if CMS experiences difficulties in accurately calculating quality scores (i.e., for PQRS, VBM, or Meaningful Use). CMS will continue to monitor implementation and adjust the duration if needed.
  • CMS will establish an ICD-10 Ombudsman to help receive and triage physician and provider problems that need to be resolved during the transition.
  • CMS will authorize advanced payments if Medicare contractors are unable to process claims within established time limits due to problems with ICD-10 implementation. 

The granting of this one-year grace period does not mean our advocacy efforts are completed.  Congress is still in session and it is important we continue advocacy efforts to insure the proposed changes are implemented as regulation.  In addition, efforts are needed to attain relief from commercial payers.  .

With less than 100 days to go until the go-live date of October 1, physicians should be testing ICD-10. If not, you need to get going now. Please make the most of CMS’ one-year grace period and tap the additional resources now offered by AMA and CMS. Also, our MSSNY website offers additional resources on our home page to bring your office up to date.

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


 

 

MLMIC



No Change in MLMIC Rates for 2015-2016; 5% Dividend Will Apply to Renewals
MLMIC has just been informed by DFS that they have approved MLMIC’s physician rate request for no base rate change effective July 1, 2015. There were no requested specialty or territory rate changes.  The 5% dividend can now be applied to the July 1, 2015 renewals to provide financial relief to renewing policyholders. If you have any questions please contact MLMIC at 1-888-793-0393.


CMS Proposes End-Of-Life Counseling Payment
On Wednesday, July 8, CMS stated that Medicare plans to reimburse physicians for having discussions with patients about advance care planning. The proposal, which was included in the agency’s 2016 physician payment rule, was praised by advocates and medical groups.

Dr. Patrick Conway, chief medical officer for CMS, said, “We think that today’s proposal supports individuals and families who wish to have the opportunity to discuss advance care planning with their physician and care team.” According to the article, the plan would allow “qualified professionals like nurse practitioners and physician assistants,” as well as physicians, to be reimbursed for face-to-face consultations with a patient and any relatives or caregivers the patient chooses to include. Dr. Conway said a final decision on the proposal will be made by Nov. 1.


CMS is seeking public comment on the proposal until Sept. 8 at rule. In particular, CMS is asking for feedback on whether the payment for end-of-life conversations should be part of annual wellness exams. You may submit electronic comments on this regulation to www.regulations.gov. Follow the instructions for “submitting a comment.”


Urologist Calls for Personalized PSA Screenings for Prostate Cancer
In the New York Times (7/6, Kapoor), urologist Deepak A. Kapoor writes an op-ed calling for changes to guidelines in prostate cancer screening, which have been discouraged since 2012 for patients without symptoms of the disease. Dr. Kapoor cites improvements in screening techniques that can better predict prostate cancer risk and the need for further testing. Kapoor explains that the 2012 guidelines stemmed from the fact that prostate-specific antigen testing may lead to unnecessary surgery among patients who did not have prostate cancer or whose cancer was likely to remain dormant. He warns that an increase in prostate cancer mortality, though not yet identified, “may be a matter of time,” as “one study concluded that annual prostate cancer deaths may increase as much as 5 percent, for the first time in more than 20 years.” Finally, Dr. Kapoor recommends that men over 40 continue to pursue PSA testing and develop a personalized screening plan, rather than avoid the test altogether.

Dr. Kapoor is Chairman and CEO of Integrated Medical Professionals, a multi-specialty group of 100 physicians in the greater New York Metropolitan. IMP is one of a growing number of physician groups that have adopted a policy of 100% membership in MSSNY and their county medical societies. 


Applications Due July 31 for Physician Practice and Repayment Programs
The NYS DOH, Office of Primary Care and Health Systems Management is pleased to announce that applications for Cycle IV of the Doctors Across New York (DANY) Physician Practice Support and Physician Loan Repayment Programs will be accepted beginning July 8 through July 31, 2015.

Physician Practice Support (PPS) provides up to $100,000 in funding to support for new practices, improvements, loan repayment or other support to physicians in exchange for a two year service commitment to provide health care in an underserved region within New York State.

Physician Loan Repayment (PLR) provides up to $150,000 in loan repayment funding in exchange for a five year service commitment to provide health care in an underserved region within New York State.

Application materials can be found on the Department of Health website here.

All applications must be submitted electronically (in PDF) to gme@health.ny.gov

Questions should be directed to: Physician Practice Support-Lianne Ramos at 518-473-3513 or gme@health.ny.gov or Physician Loan Repayment: Amy Harp at 518-473-7019 or gme@health.ny.gov


Update to Physicians Advocacy Program from KACS Law Firm
Kern Augustine Conroy & Schoppmann, P.C. is proud to announce that the Physician Advocacy Program® has expanded to include the new Premier Partner Program.

The Premier Partner Program, as a stand-alone program, or an addition to your current Physician Advocacy Program® membership, will provide members with immediate access to their own expert health law defense team, in case of a legal investigation, as well as trusted advisors to build proactive solutions regarding Asset Protection, Estate Planning, HIPAA Compliance as well as Billing and Coding Documentation for reimbursement. Premier Partner Program.


CMS Proposes Revisions to Two Midnight Rule to Give Physicians More Discretion
To respond to physician and hospital concerns regarding the “two midnight rule”, CMS has proposed to allow hospitals on a case-by-case basis to receive Part A reimbursement for patients whose stay is expected to last less than two midnights.  To read the CMS release, click here.  According to the release, for stays expected to last less than two midnights – CMS proposes the following:

  • For stays for which the physician expects the patient to need less than two midnights of hospital care (and the procedure is not on the inpatient only list or otherwise listed as a national exception), an inpatient admission would be payable under Medicare Part A on a case-by-case basis based on the judgment of the admitting physician.  The documentation in the medical record must support that an inpatient admission is necessary, and is subject to medical review.
  • CMS is reiterating the expectation that it would be rare and unusual for a beneficiary to require inpatient hospital admission for a minor surgical procedure or other treatment in the hospital that is expected to keep him or her in the hospital for a period of time that is only for a few hours and does not span at least overnight.  CMS will monitor the number of these types of admissions and plans to prioritize these types of cases for medical review.

Under the current two-midnight rule, a physician can treat Medicare beneficiaries as inpatients only when the hospital stay is expected to span two nights — from one midnight to the next — or longer.  Implementation of the rule has been delayed multiple times by Congress, including through September 30 as part of the MACRA legislation enacted this past spring.


Medicare Physician Fee Schedule on Line
Effective July 1, 2015, please be aware that the new Medicare Physician Fee Schedule is up on-line at www.NGSMedicare.com Although the increase is only 0.5%, it is an increase.  Please be sure to have your staff review the appropriate fee schedule for your locality at your earliest possible convenience.  Again, there is a 0.5% increase that became effective July 1, 2015.


Study: Medicaid Recipients Using Multiple Pharmacies Made Up Nearly Half of All Deaths Resulting From Narcotic Pain Medicine Overdose
Nearly half of all deaths resulting from an overdose of narcotic painkillers involved Medicaid recipients who used multiple pharmacies to fill their prescriptions, according to a study published in the Journal of Pain and conducted by CDC researchers. After examining “the records of more than 90,000 Medicaid recipients aged 18 to 64, who were long-term users of narcotic painkillers,” researchers found that “patients who used four pharmacies within 90 days…had the highest odds of overdosing.” http://www.jpain.org/article/S1526-5900(15)00530-1/abstract


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.  Be sure to include a caption or some identifying words. We’re open to any and all ideas and hope to hear from you!

 



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

Successful Legislative Year Concludes – June 26, 2015

drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R.Maldonado  
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Dear Colleagues:

This week has seen a significant share of federal and state legislative news.  The Supreme Court of the United States has ruled in King vs. Burwell by a vote of 6-3, that individuals in states that did not set up exchanges are eligible to receive tax subsidies.  Various folks have asked us to weigh in on the decision.  While enticing, dwelling on a discussion of the decision is purely a venting experience as it will contribute nothing other than creating greater divides.  Instead, we should accept closure on this matter and focus our energies on fixing the flaws of the ACA.  What good is a subsidized health plan that has a $6,000 deductible that encourages a patient to delay accessing care because of the out-of-pocket expense?

At the state level, we are pleased to announce that MSSNY has won two major victories—defeat of the mandated CME on pain management and change in commencement of the statute of limitations to the date of discovery.  We thank the many of you who took the time to contact their legislators to express their concerns with these bills. These are victories only in so much as we were able to stop governmentally proscribed redress of these issues.  We will NOT be able to walk away without addressing the core legitimate concerns raised by proponents of these now defunct pieces of legislation.  Instead, we will need to work with our specialty societies to devise an appropriate way to address the need for better medical education on pain management as well as responsible tort reform which includes not only redress for those harmed in the course of care but other reforms that will reduce our premium burden.

RED ALERT!!! Girding Our Loins this Summer

As we approach the 4th of July week, I draw on an archaic term to draw attention to a need to be prepared for the threat of danger.  This week, Rep. Devin Nunes, Chairman of the House Intelligence Committee stated that “the level of threat for a potential terrorist attack in the United States is at its highest.”  It has been 14 years since 9/11 and two years since the Boston bombing.  Within the past year, we dealt with an Ebola epidemic that reached our country and threatened our nation.  Presently, we face a new danger with avian flu and MERS.  MSSNY has a 50+ credit hour curriculum for Preparedness Planning which has been widely acclaimed.  It is critical that we voluntarily prepare to meet the needs of our patients PRIOR to the next potential crisis or terror event.  If we don’t volunteer, the next crisis will potentially bring a new mandate.  More importantly, it may bring casualties as a result of an unprepared medical community.  When was the last time you honed your preparedness skills and knowledge?   I would highly encourage you to use the CME link on the MSSNY website to access the curriculum. New users will need to register with an email and password. Why not use the curriculum as part of your summer reading?  It’s free to MSSNY members.  The knowledge you gain may save your family, friends, neighbors and community.

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


MLMIC



Capital_Update_Banner

Dear MSSNY and Alliance Members: 

The 2015 legislative session conclude early this morning. Through your efforts guided by MSSNY leadership and the collective efforts of MSSNY staff, MSSNY has had a very successful legislative year. 

As part of the budget, we: (1) secured $127.4M in funding for the Excess Medical Liability program; (2) defeated accreditation and onerous new regulatory requirements for urgent care practices and practices which offer after-hour care; (3) defeated the retail clinic bill; (4) defeated proposals which would have imposed additional registration and reporting requirements on physician OBS practices; and (5) secured the elimination of fees physicians currently have to pay to initiate a Workers Compensation arbitration proceeding. 

As the session concluded, we have secured many more victories which demonstrate the tangible value of MSSNY to its physician members.  These victories are discussed in further detail below but can be quickly listed: we (1) defeated the date-of-discovery statute of limitationss; (2) defeated a CME mandate for pain management, addiction and end- of-life care; (3) defeated scope-of-practice expansion by the podiatrists, dentists, optometrists and many other non-physician practitioners; (4) participated in a coalition which secured passage of legislation requiring school-based immunizations against the meningococcal disease for every person entering seventh grade and 12th grade; and (5) again defeated a last ditch effort by CVS Health to secure enactment of legislation to secure approval to establish corporate owned retail clinics statewide without establishment of public need as is normally required under the certificate of need provisions of current law. 

As we did when the budget negotiations concluded, your lobby team would again like to acknowledge each and every County and Specialty Medical Society, MSSNY leadership, and the many rank-and-file physicians who answered the call for grassroots action and met locally with their representatives or wrote a letter and/or took a day away from their practice to travel to Albany to personally meet with their elected representatives on issues of importance to all of medicine. 

Sustained physician involvement can make a difference.  Because of your efforts, we list the many successes that together we have achieved. It is our hope that you will share this newsletter with your colleagues so that we may continue to build membership in MSSNY to support even greater legislative accomplishments in the future. 

                                                                                  Your Lobby Team,
                                                                                  Liz, Moe, Pat, and Barb 

STATE SENATE LEAVES ALBANY WITHOUT PASSING UNSUSTAINABLE MALPRACTICE “DATE OF DISCOVERY” LEGISLATION
Despite a huge push from some media outlets and the trial lawyers, the State Legislature finished its 2015 session without enacting legislation to change the statute of limitations in medical liability actions.  We thank the very significant number of physicians who weighed in with their local legislators to highlight the serious adverse consequences to our health care system that would ensue if this legislation were to have been passed without any corresponding provisions to bring down New York’s already exorbitant medical liability insurance costs that for many are among the highest in the nation.  As previously reported, legislation (A.285, Weinstein) to change New York’s 2.5 year medical liability statute of limitation to a “date of discovery” rule had passed the Assembly two weeks ago.  Substantially similar legislation (S.911-A, Libous) advanced to the Senate floor on the last day of Session, but the Senate did not bring it up for a vote.  MLMIC estimates of similar legislation were that enactment of this legislation could trigger premium increases of 15%.

Conversations on this issue will continue however.  During a press conference with the Governor and Assembly Speaker discussing end of Session agreements, Senate Majority Leader Flanagan noted in response to a question from a Daily News reporter that issues like malpractice reform “have never been done in isolation” and that immediately following the conclusion of Session a series of roundtables with parties on both sides of this issue will be convened so that the issues can be addressed “sooner rather than later”.   This should present an opportunity for MSSNY and other allied hospital and health provider associations to raise issues with New York’s dysfunctional medical liability adjudication system with the goal of bringing down the cost of medical liability insurance.

MSSNY worked closely with many other provider associations also impacted by this legislation, including the Greater New York Hospital Association, Healthcare Association of NYS, the Health Care Facilities Association, other specialty medical societies, and the Lawsuit Reform Alliance of New York, in an effort to defeat this legislation.   There were print ads in several newspapers across New York State, and in the Legislative Gazette, as well as radio ads on several Albany stations, urging that the Legislature address the issue of medical liability comprehensively, and reject “stand-alone” legislation that would harm patient access to needed care.
(AUSTER, DEARS)


PHYSICIAN ACTION CREDITED WITH THE NYS ASSEMBLY TAKING NO ACTION ON CME MANDATE REQUIRMENT
The New York State Assembly did not vote on legislation requiring physicians to take three house of continuing medical education every two years.  Senate Bill 4348(Hannon) and Assembly Bill 355 (Rosenthal), would have required physicians to take three hours of continuing education on the following topics: I-STOP and drug enforcement administration requirements for prescribing controlled substances; pain management; appropriate prescribing; managing acute pain; palliative medicine; prevention, screening, and signs of addiction; responses to abuse and addiction; and end-of-life care.  The measure had passed in the NY Senate.  Thousands of physicians called or sent their legislators a letter through the Grassroots Action Center (GAC) about this legislation and urged its defeat.   MSSNY staff would like to thank all who weighed in on this issue.  Your grassroots advocacy made a real difference.  We also thank the many members of the Assembly who expressed their concern about this legislation, as well as the AMA Advocacy Resource Center staff who provided us with critically important information regarding the significant drop in opioid use in New York State compared to other states in recent years.
(CLANCY, DEARS)


CVS HEALTH’s RETAIL CLINIC BILL FAILS
As reported last week, CVS HEALTH which operates CVS Pharmacies, a pharmacy benefit manager, mail order and specialty pharmacies, and retail-based health clinic subsidiary, MinuteClinic, attempted to secure passage of legislation (S. 5458, Hannon and a similar bill A. 1411, Paulin) which would allow the establishment of corporate owned retail clinics statewide without establishment of public need as is normally required under the certificate of need provisions of current law.

The Senate bill passed the Senate and was placed on a Committee agenda in the Assembly where it failed to garner the necessary votes. Later in the week additional efforts were advanced to have the bill placed back on the Committee agenda. MSSNY working closely with the Nurses Association and other specialty medical societies succeeded in beating back this effort defeating the bill for the second time this year.

‘Convenience care clinics’ or ‘retail clinics’ operate in states outside New York in big box stores such as Walgreens or CVS retail pharmacies. They are a growing phenomenon across the nation, particularly among upper class young adults who live within a one mile radius of the clinic. These clinics are usually staffed by nurse practitioners and focus on providing episodic treatment for uncomplicated illnesses such as sore throat, skin infections, bladder infections and flu.  Physicians feel strongly that retail based clinics pose a threat to the quality of patient care and to the ability of physician practices to sustain financially and should not be allowed to propagate in New York.                                                        

Another significant concern is the potential conflict of interest posed by pharmacy chain ownership of retail clinics which provides implicit incentives for the nurse practitioner or physicians’ assistant in these settings to write more prescriptions or recommend greater use of over-the-counter products than would otherwise occur. The same self-referral prohibitions and anti-kickback protections which apply to physicians are not applicable to retail clinics, raising the concern for significant additional cost to the health care system. Rather than bend the cost continuum, we are concerned that costs will increase and   quality of care will be negatively impacted.
(DEARS, AUSTER, CLANCY, ELLMAN)


LEGISLATURE PASSES BILL TO BETTER ASSURE AVAILABILITY OF PAIN MEDICATIONS  THAT REDUCE RISK OF INAPPROPRIATE USE
The Senate and Assembly passed legislation (A.7427-A, Cusick/S.5170-A, Hannon) prior to the end of the Session to reduce barriers to patients receiving opioid medications containing abuse-dererrent technologies.  The legislation would (1) prohibit the substitution of an opioid analgesic drug product, brand or generic, with abuse-deterrent technologies with an opioid analgesic drug product lacking abuse-deterrent technologies without obtaining a new prescription from the prescriber and (2) ensure that abuse-deterrent opioid products are covered by health insurance plans in New York at least the same prescription coverage tier as non-abuse-deterrent opioid products and ensure that a patient is not required to take a non-abuse-deterrent opioid before an abuse-deterrent version.                                                                                             (AUSTER, CLANCY)

LEGISLATURE PASSES BILL TO REDUCE MEDICAID MANAGED CARE PRESCRIBING HASSLES
Legislation (A.7208, Gottfried/S.4893, Hannon) to reduce hassles experienced by physicians when prescribing certain medications for their patients insured through Medicaid Managed Care plans was passed by the Senate and Assembly towards the end of the Session.   MSSNY articulated its strong support for this legislation, and will urge the Governor to sign this legislation into law. 

For many years, New York State has held to the important principle that patients covered under the Medicaid “fee for service” program are entitled to receive the prescription medications that are recommended by their treating physician, and such decisions may not be overruled by Medicaid administrative staff.  After the Medicaid pharmacy benefit was included within Medicaid managed care, in 2012, the Legislature and Governor agreed to assure that these important “prescriber prevails” protections continued to be in effect for several classes of medications needed by patients affected with very serious health conditions, including medications in the anti-depressant, anti-retroviral,  anti-rejection, seizure, epilepsy, endocrine, hematologic, immunologic and atypical antipsychotic therapeutic classes. Since that time, many physicians have reported situations where health insurers forced them to wait an unreasonably long time to receive approval to assure their patients could receive a needed medication from one of these drug classes, despite the “prescriber prevails” protections.  This legislation would help to reduce these hassles, and assure that patients can receive needed medications more quickly.
 (AUSTER, DEARS)


AS SESSION ENDS MSSNY IS SUCCESSFUL IN PREVENTING PASSAGE OF SCOPE OF PRACTICE BILLS
The following are among many scope-of-practice bills that MSSNY defeated this year as the Legislative Session for 2015 concludes:

  1. 816 (Libous)/ A.3329 (Morelle) – a bill that would permit certain dental surgeons to perform a wide range of medical surgical procedures involving the hard or soft tissues of the oral maxillofacial area. This could include cosmetic surgery, such as face lifts, rhinoplasty, bletheroplasty, and other procedures, and would allow them to do these procedures in their offices, although they are not included in the office-based surgery law that govern office-based surgery for physicians.  This bill remains  in the Higher Education Committee in both the Senate and Assembly.
  2. 719 (Pretlow)/ S.4600 (Libous) – a bill that would expand the scope of practice of podiatrists to diagnos, treat, operate or prescribe for cutaneous conditions of the ankle up to the level of the knee, which could include skin cancers or diabetic wounds.  It does not have to be a wound that is “contiguous with”, but only has to be “related to” a condition of the foot or ankle.  It would eliminate the requirement for direct supervision of podiatrists training to do this additional work, and would allow them to basically train themselves.  This bill remains in the Higher Education Committee in the Senate and Assembly.
  3. 7035 (Perry)/ S.4917 (LaValle) – a bill that would license naturopaths and create a scope of practice for them that could be interpreted in many ways, and is not clear as to their limits of practice. It would allow them to practice as primary care providers and call themselves naturopathic doctors. Despite claims that they cannot do invasive procedures, it would allow them to immunize and perform cryotherapy.  This bill remains in the Higher Education Committee in the Senate and Assembly.
  4. 2063 (Libous)/ A.2803 (Paulin) – a bill that would authorize optometrists to use and prescribe various oral therapeutic drugs, which have a systemic effect on the body, which they are not trained to deal with. Most of the requested drugs are rarely, if ever, used by ophthalmologists, and are unnecessary for optometrists to use.  This bill remains in the Higher Education Committee in the Senate and Assembly.
  5. 215-A (Martins)/ A.4391 (O’Donnell) – a bill to permit chiropractors to form LLCs with physicians as partners. This bill could allow chiropractors, who own a controlling interest in the LLC to tell employed physicians, or even a minority partner, how to practice and what tests to conduct.  This bill passed the Senate, and remains in the Higher Education Committee in the Assembly.
  6. 5824 (Lanza) – a bill that would provide for the certification of psychologists to prescribe drugs. This bill remains in the Senate Higher Education Committee.  There is no same-as bill in the Assembly.

The outcome of all of these bills is a resounding victory for TEAM MSSNY and all of our physicians who reached out to their Legislators to oppose them.                                                                                                                            (ELLMAN, DEARS)


COLLABORATIVE DRUG THERAPY MANAGEMENT BILL PASSES BOTH HOUSE OF THE LEGISLATURE- ISSUES RAISED BY MSSNY ADDRESSED.

Legislation (A. 5805-A, McDonald/S. 4857-A, LaValle) which would extend the authorization of pharmacists to perform collaborative drug therapy management (CDTM) in certain settings passed during the final days of session and will soon be sent to the Governor for his consideration.  The final bill addressed many of the numerous issues raised by MSSNY with the initial version of this bill.

MSSNY was concerned that the bill removed protections which had been included when this demonstration program was first enacted which assured that the treating physician remained in control of the care provided to the patient. Specifically, the initial version of the bill would have allowed for the substitution of a drug which differed from that initially prescribed by the patient’s physician without authorization by the treating physician. The bill was modified to prohibit such substitutions or adjustments without authorization by the treating physician. Moreover, the initial version of the bill would have eliminated language which required the patient to consent to the collaborative drug therapy management. This protection was restored at the request of MSSNY. The initial version of the bill had inserted the term “prescribing” when ordering an adjustment or managing a drug regimen. MSSNY noted that “prescribing” remains outside of the pharmacist’ scope of practice and this term was removed from the bill. The original version of the bill would have extended to NPs and PAs the ability to collaborative with a pharmacist in collaborative drug therapy management. The extension of such collaborative authority was removed at MSSNY’s request. Lastly, MSSNY was concerned by the extension of CDTM to a nursing home or residential health care facility setting primarily because these settings are not well staffed by physicians. The final bill allowed for the extension of CDTM to other hospital settings including a nursing home but only if it has an on-site pharmacy staffed by a licensed pharmacist. The bill did not extend CDTM however to dental clinics, dental dispensaries, residential health care facilities and rehabilitation centers.

The bill extended the collaborative drug therapy demonstration with this parameter for three ore years.

MSSNY is grateful to the sponsors of the bill and the Chairs of the Higher Education Committees for their consideration of our concerns in constructing this on-going demonstration.                     
(DEARS, ELLMAN)
 


NYS LEGISLATURE APPROVES BILL TO ALLOW PHARMACISTS TO PROVIDE ADULT IMMUNIZATIONS; BILL WILL NOW GO TO GOVERNOR FOR CONSIDERATION
Pharmacists will expand the list of immunizations that they can provide to adults under legislation that passed the New York State Legislature.  A. 123B, Paulin/S. 4739A,Hannon would add Diphtheria, Tetanus and Pertussis (DPT) to the list of vaccines that can be administered by pharmacists. The bill now goes before Governor Andrew Cuomo for his consideration and action.    The bill would allow physicians and nurse practitioners to authorize non-patient specific scripts for pharmacists to administer any of these vaccines.  The law currently allows pharmacists to administer influenza and pneumococcal vaccines to adults through a non-patient specific script and to administer the acute herpes zoster and meningococcal vaccines to adults under a patient specific script.  The bill also authorizes the pharmacists to administer emergency treatment for anaphylaxis.   Importantly, the bill requires the pharmacist to report the administration of the vaccine to the physician and/or primary health care practitioner, by electronic transmission or facsimile and, to the extent practicable, to make himself or herself available to the discuss the outcome of such immunization, including any adverse reactions with the attending physician and/or to report the administration of the vaccine to the statewide or NY city wide registry.   Under the bill’s provisions, the pharmacist is also required to inform the patient of the total cost of the immunization, including whether insurance coverage is available, and if the vaccine is not covered, the pharmacists must also inform the patient of the possibility that the immunization may be covered when administered by a primary care physician or a nurse practitioner.   The bill stipulates that the administration of a vaccine must occur in a privacy area to ensure the patient’s privacy and that the adult immunization schedule by the Advisory Committee for Immunizations Practices must be clearly posted for patients to read. The bill also authorizes that the commissioner of health can declare an outbreak or the threat of an outbreak; that he/she may issue a non-patient specific regimen applicable statewide.  The bill also contains a three year sunset.   The Medical Society of the State of New York opposed this measure, because of its belief that this policy would further fracture the medical home.
(CLANCY, DEARS, ELLMAN) 


HOUSE PASSES IPAB REPEAL LEGISLATION
This week the US House of Representatives passed legislation (HR 1190) to repeal the Independent Payment Advisory Board (IPAB) by a vote of 244-154 (Roll call here).  Eleven Democrats, including New York Representative Sean Patrick Maloney, joined 233 Republicans in voting in favor of passage (including New York Representatives Chris Collins, Dan Donovan, Chris Gibson, Richard Hanna, John Katko, Peter King, Elise Stefanik and Lee Zeldin).  As H.R. 1190 was offset with funding from the ACA’s Public Health and Prevention Fund, several lawmakers commented that the number of Democrats voting for IPAB repeal would have increased had the bill been offset differently.

The IPAB is charged with making recommendations to cut Medicare expenditures if spending growth reaches an arbitrary level that can only be overturned by a supermajority of Congress.  MSSNY recently signed on to a patient and provider advocacy letter in support of repeal of the IPAB.  The letter notes that “The Independent Payment Advisory Board (IPAB), a provision of the Patient Protection and Affordable Care Act (PPACA), not only poses a threat to that access but also, once activated, will shift healthcare costs to consumers in the private sector and infringe upon the decisionmaking responsibilities and prerogatives of the Congress. We request your support to repeal IPAB.”    
(AUSTER)


MSSNY JOINS OTHER STATE MEDICAL SOCIETIES TO URGE 2-YEAR ICD-10 TRANSITION PERIOD
MSSNY continued working with the medical associations of California, Florida and Texas, as well as with the AMA, in support of activities to assure a more fair transition to the ICD-10 coding set.  This week the CMA, FMA and TMA together with MSSNY wrote to the US Senate and House of Representatives leadership to urge a two-year ICD-10 “grace period” when physicians and other health care providers are required to use ICD-10 codes starting October 1, 2015.   MSSNY also joined a similar federation sign-on letter initiated by the AMA.   Moreover, MSSNY President Dr. Joseph Maldonado and Vice-President Dr. Charles Rothberg joined physician leaders and staff from the four state medical associations in a conference call meeting with CMS staff as a follow-up to a similar letter sent to Acting CMS Administrator Andy Slavitt last week.   While the “Big 4” letter to Congress notes that the groups’ first request is to pass legislation such as HR 2126 (Poe), to stop the implementation of ICD-10 altogether, it also urges that “for those physicians who have adopted ICD-10, we ask that the payers allow a dual coding system where physicians can bill using either ICD-9 or ICD-10… If these requests are not achievable, we strongly encourage you to pass legislation such as HR 2652, the Protecting Patients and Physicians Against Coding Act, by Congressman Gary Palmer (AL-06) and others, or simply join our call for CMS to implement a two-year ICD-10 grace period…We believe that two years of transition time, on-the-job learning by physicians — plus our continued ICD-10 educational activities — will result in a much less disastrous transition to this overwhelmingly complicated new coding system.”

Our group efforts have been noted in multiple media outlets, including here and here.
(AUSTER)


SENATE FAILS TO ACT ON INCLUING E-CIGARETTES UNDER CLEAN INDOOR AIR ACT
The NY Senate failed to act on in waning hours of the legislative session to prohibit e-cigarette use in all public places in accordance with the NYS Clean Indoor Air Act.  A.5595B/S.2202B sponsored by Assemblywoman Linda Rosenthal, and Senator Kemp Hannon, passed in the NY State Assembly.  In recent years, there has been the proliferation of electronic cigarettes which threaten to reverse the progress New York has made preventing children from starting this deadly habit and helping smokers to quit.  Through unregulated marketing and widespread use in public areas, electronic cigarettes are re-normalizing “smoking” to kids while exposing workers and patrons to secondhand emissions.  Use of e-cigarettes in indoor public places also makes it very difficult to enforce the existing clean indoor air law.  The Medical Society of the State of New York has joined with other health organizations calling for passage of this measure.   The measure is supported by: American Cancer Society Cancer Action Network, American Heart Association/ American Stroke Association, American Lung Association in New York, Americans For Nonsmokers’ Rights, Campaign for Tobacco-Free Kids, County Health Officials of New York (NYSACHO), Health Plan Association, League of Women Voters of New York State, New York Chapter American College of Physicians, Services Inc., New York State Academy of Family Physicians, New York State Public Health Association, Roswell Park Cancer Institute.  MSSNY has significant House of Delegates policy calling for inclusion of e-cigarettes under the Clean Indoor Air.    This will continue to be one of MSSNY’s public health legislative priorities.
(CLANCY, ELLMAN)

For more information relating to any of the above articles, please contact the appropriate contributing staff member at the following email addresses:       

pschuh@mssny.org ldears@mssny.org   mauster@mssny.org  
pclancy@mssny.org bellman@mssny.org    

 

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Changes to the Medicare Opt-Out Law for Physicians and Practitioners
Prior to enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), physician/practitioner opt-out affidavits were only effective for two years. As a result of changes made by MACRA, valid opt-out affidavits signed on or after June 16, 2015, will automatically renew every two years. If physicians and practitioners that file affidavits effective on or after June 16, 2015 do not want their opt-out to automatically renew at the end of a two year opt-out period, they may cancel the renewal by notifying all Medicare Administrative Contractors with which they filed an affidavit in writing at least 30 days prior to the start of the next opt-out period. Valid opt-out affidavits signed before June 16, 2015, will expire two years after the effective date of the opt out. If physicians and practitioners that filed affidavits effective before June 16, 2015 want to extend their opt out, they must submit a renewal affidavit within 30 days after the current opt-out period expires to all Medicare Administrative Contractors with which they would have filed claims absent the opt-out.(Updated on 06/18/2015) 

Medicare Eligible Professionals: Take Action by July 1 to Avoid 2016 Medicare Payment Adjustment
Payment adjustments for eligible professionals that did not successfully participate in the Medicare EHR Incentive Program in 2014 will begin on January 1, 2016. Medicare eligible professionals can avoid the 2016 payment adjustment by taking action by July 1 and applying for a 2016 hardship exception.

The hardship exception applications and instructions for an individual and for multiple Medicare eligible professionals are available on the EHR Incentive Programs website, and outline the specific types of circumstances that CMS considers to be barriers to achieving meaningful use, and how to apply.

To file a hardship exception, you must:

  • Show proof of a circumstance beyond your control.
  • Explicitly outline how the circumstance significantly impaired your ability to meet meaningful use.

Please note: The application includes specific instructions for documentation requirements for each category, please check the instructions and form carefully for the documentation for the category for which you are applying. While supporting documentation must be provided for certain hardship exception categories, CMS does not require additional documentation for 2014 Edition certified EHR technology issues. You should, however, retain documentation for your own records. CMS will independently review each application and any supporting documentation.

You do not need to submit a hardship application if you:

  • are a newly practicing eligible professional
  • are hospital-based: a provider is considered hospital-based if he or she provides more than 90% of their covered professional services in either an inpatient (Place of Service 21) or emergency department (Place of Service 23), and certain observation services using Place of Service 22 ; or
  • Eligible professionals with certain PECOS specialties (05-Anesthesiology, 22-Pathology, 30-Diagnostic Radiology, 36-Nuclear Medicine, 94-Interventional Radiology)

CMS will use Medicare data to determine your eligibility to be automatically granted a hardship exception.


Need Guidance for ICD-10? Come to MSSNY Website!
Most physicians won’t need to know ALL the new ICD-10 CM diagnosis codes. However,

if you haven’t done so already, you should pick your top 10 or 20 ICD-9 Codes for your practice/specialty and “crosswalk” them to the new ICD-10 CM codes.

Please visit the following websites, for assistance:

www.roadto10.org

http://www.icd10data.com/Convert

http://www.icd10data.com/ICD10CM/Codes

http://www.icd10charts.com/

Reminder: Medicare Does Not Preauthorize Coverage for Items or Services
National Government Services has seen an increase in calls to their Provider Contact Center (PCC), asking if Medicare preauthorizes coverage for provided items and services. As a reminder, Medicare does not preauthorize coverage for items or services that will receive payment under Part A or Part B, except for custom wheelchairs.

Additional information is available in the MLN Matters article SE0916 Revised, “Medicare Parts A and B Coverage and Prior Authorization.” Refer to this MLN and update any applicable internal procedures and policies with this information and share with internal staff.
Related Content
SE0916 Revised: Medicare Parts A and B Coverage and Prior Authorization

NY Medicaid Management Information System (NYMMIS) Project Website

The New York State Department of Health and Xerox State Healthcare, LLC are working diligently on the design and development of the new Medicaid Management Information System, called NYMMIS.

NYMMIS has an interim website online that was created to serve as an ‘information billboard.’ It will be used as a main source for communicating information by providing updates and email bulletins regarding the implementation of the new system.  Updates will be provided on a regular basis in an effort to share relevant NYMMIS information that may potentially impact providers’ business processes. The interim website hosts a ListServ signup section.  Those who sign up to the ListServ are able to receive timely emails that contain any updates on the project that might affect them.

The interim NYMMIS website will have no impact on eMedNY nor will it be used for provider billing or other transactions. Please visit: www.interimnymmis.com

Skinny Jeans Have Their Down Side
A  report in the Journal of Neurology, Neurosurgery and Psychiatry, that tells of a case “of a 35-year-old woman who wound up lying prone on the pavement, unable to get up, after spending the day in skinny jeans while helping a relative move. By the time the doctors saw the patient, both her legs were so swollen below the knee that the medical team had to cut the jeans off her. She also had severe weakness in her feet and ankles and was not able to walk.”


Doctors without Borders Reception in Woodbury L.I.
On August 12 at 6:00pm at the Liquid Outdoor Lounge @ the Woodbury Country Club, 884 Jericho Turnpike, Woodbury NY 11797, Nikhil G. Jaiswal, age 13, is hosting a charity reception featuring hors d’oeuvres and raffles for Doctors without Borders. (Nikhil is the son of Arun Jaiswal, a member of Suffolk County Medical Society.) Tesla Motors will be showcasing their award-winning car, the Model S. All donations are tax deductible. If you would like to donate by check, please make it out to Doctors Without Borders and bring it to the event. To attend the event, the minimum donation is $75 per person. For more information contact Nikhil G. Jaiswal here.


Classifieds

Board Eligible Plastic Surgeon Seeks Full Time Position
Brookdale University Hospital Attending Emeritus is resuming practice after retirement. 20 years private practice experience in cosmetic, reconstructive and hand surgery. Plastic Surgery Board Eligible. Seeks full time position with NYS group; flexible salary, will relocate. 6 month on the job preceptorship required to activate NY Medical license. Please email fredricjcohenmd@aol.com.

Dr. Cohen

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

Legislature Not Going Home Yet – June 19, 2015

drmaldonado PRESIDENT’S MESSAGE
 Dr. Joseph R.Maldonado  
asset.find.us.on.facebook.lg    Twitter_logo_blue1

Dear Colleagues:

It had been my hope that this week’s post would relay good news regarding our efforts in Albany.  Alas, the legislative session has gone into overtime and will be going into next week.  Thanks to all of you who have reached out to your Assemblyperson and Senator asking for their support of MSSNY’s position against the mandated pain management CME and extending the Statute of Limitations for filing a malpractice claim to run from the date of discovery.  Please keep an eye on your emails from MSSNY during the next five days as unexpected surprises may require us to issue an ALERT asking you to contact your state legislators once again.

At the federal level, we continue our joint efforts with other state and specialty societies in seeking assistance for physicians as we transition to ICD-10 on October 1, 2015. While MSSNY and many other physician associations strongly support and have advocated for postponing ICD-10, the efforts to delay its implementation or to completely bypass ICD-10 have been unsuccessful.  At this time, many of us in leadership at the state and specialty society level believe our efforts to assist physicians with the challenges of ICD-10 implementation should be directed towards establishing a grace period.  Such a grace period would allow for physicians to begin compliance with the requirement to use ICD-10. However, during said period, physicians would not be penalized for errors made in coding using the ICD-10 codes.   Data would be collected and physicians would be notified concerning errors in coding so that they can make appropriate changes in future coding.  However, payment for services would not be delayed because of errors.

This week, the four states with the largest numbers of physicians signed a joint letter to CMS’ Acting Administrator Mr. Andy Slavitt asking him to implement a two-year grace period.  This period is consistent with the recent vote of the House of Delegates of the AMA.  I would encourage you to review the attached letter and write to your Congressperson and our U.S. Senators asking for their support of this request.

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


MLMIC



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LEGISLATIVE SESSION CONTINUES INTO NEXT WEEK- DEAL ON RENT CONTROL REMAINS ELUSIVE
A deal on rent control has not yet been reached. Late last evening the Senate and Assembly passed a five day extender of the rent control laws until Tuesday, June 23rd. The Senate then left town. The Assembly remained in Session on Friday. Physicians must remain vigilant on two issues discussed in greater detail in separate articles below: (1) the Date of Discovery state of limitations bill (A.285, Weinstein and similar proposal S.911A, Libous) which has passed the Assembly and (2) the CME mandate on pain management, addiction and end of life care which has passed the Senate and is on the floor of the Assembly. Over the weekend we urge physicians to continue their grassroots efforts by sending letters to their legislators urging defeat of each of these bills.

Link to Date of Discovery Statute of Limitations Letter in Opposition.

Link to CME Mandate Letter in Opposition. 


PHYSICIANS MUST CONTINUE TO CONTACT THEIR SENATORS TO OPPOSE HUGE MEDICAL LIABILITY EXPANSION LEGISLATION
With the Legislature continuing its Session beyond its scheduled end date, all physicians must continue to contact their Senators to urge that they oppose legislation (S.911-A, Libous) that could drastically increase New York’s already exorbitantly high medical liability premiums by changing the medical liability Statute of limitations to a “Date of Discovery” rule.   The letter can be sent here.   Last week, the bill was passed by the New York State Assembly by a 120-25 vote (roll call here).

MLMIC’s estimate based upon similar legislation is that could single bill could increase physician liability premiums by an untenable 15%!    While many other states do have some exceptions to their statutes of limitation for “discovery” of alleged negligent acts, the vast majority of these states also place strict limitations on non-economic damages.  As New York physicians continue to pay liability premiums that are among the very highest in the country and face dwindling payments from Medicare and commercial insurers, any changes to permit more lawsuits must be considered only as part of a comprehensive package that seeks to bring down these exorbitant costs.

MSSNY is working with many other provider associations also impacted by this legislation, including hospitals, nursing homes, other specialty societies and the Lawsuit Reform Alliance of New York, in an effort to defeat this disastrous legislation.  This past week, there were print ads in several newspapers across New York State, and radio ads on several Albany stations, urging that the Legislature address the issue of medical liability comprehensively, and reject “stand-alone” legislation that would harm patient access to needed care.    To view the print ad, click here.
(AUSTER, DEARS)


NYS SENATE PASSES CME MANDATE BILL; BILL STILL ON ASSEMBLY DEBATE LIST —URGENT ACTION IS NEEDED TO OPPOSE THIS LEGISLATION
Legislation requiring physicians to take three house of continuing medical education on pain management, palliative care, addiction and ISTOP, has passed the NY Senate and is on the Assembly debate list and could be voted on at any time.   Physicians are urged to contact their assembly members and urge them to reject this legislation.  Physicians are urged to send a letter urging defeat of this measure.  Or they can call their member at the generic Assembly phone number (518)455-4100 and ask to speak with him/her.

Senate Bill 4348(Hannon) and Assembly Bill 355 (Rosenthal), would require physicians to take three hours of continuing education on the following topics: I-STOP and drug enforcement administration requirements for prescribing controlled substances; pain management; appropriate prescribing; managing acute pain; palliative medicine; prevention, screening, and signs of addiction; responses to abuse and addiction; and end-of-life care.  When speaking to their Assembly members, physician can speak about how the mandate to check the Prescription Monitoring Program (PMP) has change behavior.   Notably, New York State now ranks 50th in overall utilization of opioids and has shown a -12.4% reduction in the filling of hydrocodone prescriptions between 2013 when the ISTOP law was first implemented and 2014.  This comparison data is from IMS, Inc. Plymouth Meeting PA, — a company that provides information, services and technology for the healthcare industry.  It is the largest vendor of U.S. physician prescribing data in the nation.  It was provided to MSSNY from the American Medical Association.   Nationwide, there are 13 states that require physicians and other prescribers to complete either a one-time course or a course every two to four years in pain management and opioid prescribing.   All of these states ranked higher than New York State (50th) in overall utilization of opioids (annual prescriptions per capita 2014 Opioid Products).    New York State was 46th in the growth in opioid utilization by state (per change in filled prescription 2014 vs 2013)—only two states with CME had a greater reduction in the growth of opioid utilization.  New York State also ranked 45th in growth on hydrocodone utilization by state (NY saw a reduction of -12.4% in filled prescriptions between 2014 vs. 2013)—again only two states that require CME had greater reduction—Rhode Island ( a state that requires CME) had a -12.9% reduction in filled prescriptions.  According to IMS Health, Inc., NY is ranked 49 in overall utilization of Controlled Substances II and 41 in growth in Controlled Substance II utilization.  Overall utilization of Controlled Substance III, New York State is ranked 27th, however, growth in Controlled Substance III was reduced by -5.8% and the state is ranked 50th in growth of utilization with all CME states above New York.

This data shows strong evidence that prescribing practices by physicians have changed within the last two years due to the implementation of ISTOP in August 2013 that required physicians to check the Prescription Monitoring Program (PMP) prior to issuing a prescription for any controlled substances.   There has been strong physician compliance with the law and in many respect; it has been successful in achieving its goals to significantly reduce doctor shopping and reduce drug diversion.   According to the New York State Department of Health and the policy paper by Brandeis University: Mandating PDMP Participation by Medical Providers: Current Status and Experience in Selected States—  since the implementation of ISTOP drug diversion in New York State has been reduced by 75%. MSSNY believes that the implementation of the I-STOP law and the statutory requirement for all prescribers to check the PMP prior to issuing a Controlled Substances II, III, IV prescription has already changed prescribing practices within New York State in a relatively short period of time.   It would appear from the data noted above the PMP has changed behavior more significantly than would  continuing medical education coursework and training  in the area of  pain management and opioid use as noted by the data by the IMS Health, Inc.  MSSNY also believes that the implementation of the E-prescribing requirement for controlled substances and non-controlled substances in New York State, will also significantly impact prescriber’s behavior and the exercise of their clinical judgment in the use of controlled substances.
(CLANCY, DEARS)


NYS ASSEMBLY PASSES BILL TO INCLUDE E-CIGARETTES UNDER CLEAN INDOOR AIR ACT; ACTION IS NEED IN NYS SENATE

The NY State Assembly passed legislature to prohibit e-cigarette use in all public places in accordance with the NYS Clean Indoor Air Act.  The measure is pending in the NY State Senate.  A. 5595B/Senate Bill 2202B sponsored by Assemblywoman Linda Rosenthal, and Senator Kemp Hannon and must see action in the Senate before it can become law.   Physicians are urged to contact their senators in support of this measure by sending a letter.

Patients can also send a letter through MSSNY Grassroots Action Center.

In 2003, New York updated its Clean Indoor Air Act by prohibiting the use of tobacco products in all workplaces. The purpose was to protect workers from the dangers of secondhand smoke and to provide clean indoor air for the overwhelming majority of New Yorkers who do not smoke.  Due to this law and other important steps that New York has taken, the state have seen major reductions in smoking rates.  However in recent years, there has been the proliferation of electronic cigarettes which threaten to reverse the progress New York has made preventing children from starting this deadly habit and helping smokers to quit.  Through unregulated marketing and widespread use in public areas, electronic cigarettes are re-normalizing “smoking” to kids while exposing workers and patrons to secondhand emissions.  Use of e-cigarettes in indoor public places also makes it very difficult to enforce the existing clean indoor air law.  The Medical Society of the State of New York has joined with other health organizations calling for passage of this measure.   The measure is supported by: American Cancer Society Cancer Action Network, American Heart Association/ American Stroke Association, American Lung Association in New York, Americans For Nonsmokers’ Rights, Campaign for Tobacco-Free Kids, County Health Officials of New York (NYSACHO), Health Plan Association, League of Women Voters of New York State, New York Chapter American College of Physicians, Services Inc., New York State Academy of Family Physicians, New York State Public Health Association, Roswell Park Cancer Institute.  MSSNY has significant House of Delegates policy calling for inclusion of e-cigarettes under the Clean Indoor Air.
(CLANCY, ELLMAN)


LEGISLATURE PASSES BILL TO REDUCE MEDICAID MANAGED CARE PRESCRIBING HASSLES
Legislation (A.7208, Gottfried/S.4893, Hannon) to reduce hassles experienced by physicians when prescribing certain medications for their patients insured through Medicaid Managed Care plans passed the Senate and Assembly this week.   MSSNY articulated its strong support for this legislation, along with many other patient advocacy organizations, and will urge the Governor to sign this legislation into law. 

For many years, New York State has held to the important principle that patients covered under the Medicaid “fee for service” program are entitled to receive the prescription medications that are recommended by their treating physician, and such decisions may not be overruled by Medicaid administrative staff.  After the Medicaid pharmacy benefit was included within Medicaid managed care, in 2012, the Legislature and Governor agreed to assure that these important “prescriber prevails” protections continued to be in effect for several classes of medications needed by patients affected with very serious health conditions, including medications in the anti-depressant, anti-retroviral, anti-rejection, seizure, epilepsy, endocrine, hematologic, immunologic and atypical antipsychotic therapeutic classes. Since that time, many physicians have reported situations where health insurers forced them to wait an unreasonably long time to receive approval to assure their patients could receive a needed medication from one of these drug classes, despite the “prescriber prevails” protections.  This legislation would help to reduce these hassles, and assure that patients can receive needed medications more quickly.
(AUSTER, DEARS) 


SCHOOL BASED MENINGOCOCCAL IMMUNIZATION LEGISLATION PASSES NYS LEGISLATURE; WILL NOW GO TO GOVERNOR
A.791C/S. 4324A, sponsored by Assemblywoman Aileen Gunther and Senator Kemp Hannon, has passed the NYS Legislature.   The bill will now go to Governor Andrew Cuomo for his consideration.   The bill will require school-based immunizations against the meningococcal disease for every person entering seventh grade and 12th grade.  The Medical Society of the State of New York is part of a coalition of organizations supporting this legislation.  This bill is consistent with the Advisory Committee on Immunization Practices.   Organizations in support of the measure included the GMHC, the American Academy of Pediatrics NYS Chapter, District II, Latino Commission on AIDS, Kimberly Coffey Foundation, March of Dimes, Meningitis Angels, National Meningitis Association, the Nurse Practitioner Association New York State, New York State Academy of Family Physicians, and the New York Chapter of the American College of Physicians.
(CLANCY)


CVS HEALTH MAKES ADDITIONAL EFFORT AT THE END OF SESSION FOR AUTHORITY TO ESTABLISH RETAIL CLINICS- MASSNY WORKING WITH NURSES ASSOCIATION AGAINST THIS EFFORT
CVS HEALTH which operates CVS Pharmacies, a pharmacy benefit manager, mail order and specialty pharmacies, and retail-based health clinic subsidiary, MinuteClinic, made another effort during the waning days of the legislative session to secure passage of legislation (S. 5458, Hannon and a similar bill A. 1411, Paulin) to secure approval to establish retail clinics statewide without establishment of public need as is normally required under the certificate of need provisions of current law.

The Senate bill passed the Senate earlier this week. MSSNY working closely with the Nurses Association and other medical specialties sought to defeat the Assembly proposal when considered by the Assembly Codes Committee earlier this week. The bill was defeated in Committee. Later in the week, however, additional efforts were advanced to have the bill placed back on the Committee agenda. Again, MSSNY and Nurses Association lobbyists worked together to assure that the bill remained in Committee.

Earlier this year MSSNY successfully advocated to the legislature to reject a similar initiative advanced as part of the proposed state budget.  ‘Convenience care clinics’ or ‘retail clinics’ operate in states outside New York in big box stores such as Walgreens or CVS retail pharmacies. They are a growing phenomenon across the nation, particularly among upper class young adults who live within a one mile radius of the clinic. These clinics are usually staffed by nurse practitioners and focus on providing episodic treatment for uncomplicated illnesses such as sore throat, skin infections, bladder infections and flu.  Physicians feel strongly that retail based clinics pose a threat to the quality of patient care and to the ability of physician practices to sustain financially and should not be allowed to propagate in New York.

Another significant concern is the potential conflict of interest posed by pharmacy chain ownership of retail clinics which provides implicit incentives for the nurse practitioner or physicians’ assistant in these settings to write more prescriptions or recommend greater use of over-the-counter products than would otherwise occur. The same self-referral prohibitions and anti-kickback protections which apply to physicians are not applicable to retail clinics, raising the concern for significant additional cost to the health care system. Rather than bend the cost continuum, we are concerned that costs will increase and   quality of care will be negatively impacted.

MSSNY will remain vigilant against any further efforts to advance this measure before the end of session.
(DEARS, AUSTER)


COLLABORATIVE DRUG THERAPY MANAGEMENT BILL PASSES BOTH HOUSE OF THE LEGISLATURE- ISSUES RAISED BY MSSNY ADDRESSED.
Legislation (A. 5805-A, McDonald/S. 4857-A, LaValle) has passed both houses of the Legislature which would extend the authorization of pharmacists to perform collaborative drug therapy management (CDTM) in certain settings.  The final bill addressed many of the numerous issues raised by MSSNY with the initial version of this bill.

MSSNY was concerned that the bill removed protections which had been included when this demonstration program was first enacted which assured that the treating physician remained in control of the care provided to the patient. Specifically, the initial version of the bill would have allowed for the substitution of a drug which differed from that initially prescribed by the patient’s physician without authorization by the treating physician. The bill was modified to prohibit such substitutions or adjustments without authorization by the treating physician. Moreover, the initial version of the bill would have eliminated language which required the patient to consent to the collaborative drug therapy management. This protection was restored at the request of MSSNY. The initial version of the bill had inserted the term “prescribing” when ordering an adjustment or managing a drug regimen. MSSNY noted that “prescribing” remains outside of the pharmacist’ scope of practice and this term was removed from the bill. The original version of the bill would have extended to NPs and PAs the ability to collaborative with a pharmacist in collaborative drug therapy management. The extension of such collaborative authority was removed at MSSNY’s request. Lastly, MSSNY was concerned by the extension of CDTM to a nursing home or residential health care facility setting primarily because these settings are not well staffed by physicians. The final bill allowed for the extension of CDTM to other hospital settings including a nursing home but only if it has an on-site pharmacy staffed by a licensed pharmacist. The bill did not extend CDTM however to dental clinics, dental dispensaries, residential health care facilities and rehabilitation centers.

The bill extended the collaborative drug therapy demonstration with this parameter for three more years.

MSSNY is grateful to the sponsors of the bill and the Chairs of the Higher Education Committees for their consideration of our concerns in constructing this on-going demonstration.     
(DEARS, ELLMAN)


NYS LEGISLATURE APPROVES BILL TO ALLOW PHARMACISTS TO PROVIDE ADULT IMMUNIZATIONS; BILL WILL NOW GO TO GOVERNOR FOR CONSIDERATION
Pharmacists will expand the list of immunizations that they can provide to adults under legislation that has passed the New York State Legislature.  A. 123B/S. 4739A, sponsored by Assemblywoman Amy Paulin and Senator Kemp Hannon, would add Diphtheria, Tetanus and Pertussis (DPT) to the list of vaccines that can be administered by pharmacists. The bill now goes before Governor Andrew Cuomo for his consideration and action.    The bill would allow physicians and nurse practitioners to authorize non-patient specific scripts for pharmacists to administer any of these vaccines.  The law currently allows pharmacists to administer influenza and pneumococcal vaccines to adults through a non-patient specific script and to administer the acute herpes zoster and meningococcal vaccines to adults under a patient specific script.  The bill also authorizes the pharmacists to administer emergency treatment for anaphylaxis.   Importantly, the bill requires the pharmacist to report the administration of the vaccine to the physician and/or primary health care practitioner, by electronic transmission or facsimile and, to the extent practicable, to make himself or herself available to the discuss the outcome of such immunization, including any adverse reactions with the attending physician and/or to report the administration of the vaccine to the statewide or NY city wide registry.   Under the bill’s provisions, the pharmacist is also required to inform the patient of the total cost of the immunization, including whether insurance coverage is available, and if the vaccine is not covered, the pharmacists must also inform the patient of the possibility that the immunization may be covered when administered by a primary care physician or a nurse practitioner.   The bill stipulates that the administration of a vaccine must occur in a privacy area to ensure the patient’s privacy and that the adult immunization schedule by the Advisory Committee for Immunizations Practices must be clearly posted for patients to read. The bill also authorizes that the commissioner of health can declare an outbreak or the threat of an outbreak; that he/she may issue a non-patient specific regimen applicable statewide.  The bill also contains a three year sunset.   The Medical Society of the State of New York opposed this measure, because of its belief that this policy would further fracture the medical home.      (CLANCY, DEARS, ELLMAN)


AS SESSION WINDS DOWN SCOPE OF PRACTICE BILLS STATUS UNCHANGED WITH TWO EXCEPTIONS
The following are among many scope-of-practice bills that MSSNY is opposing as the Legislative Session draws to a close for 2015:

  1. 816 (Libous)/ A.3329 (Morelle) – a bill that would permit certain dental surgeons to perform a wide range of medical surgical procedures involving the hard or soft tissues of the oral maxillofacial area. This could include cosmetic surgery, such as face lifts, rhinoplasty, bletheroplasty, and other procedures, and would allow them to do these procedures in their offices, although they are not included in the office-based surgery law that govern office-based surgery for physicians.  This bill remains in the Higher Education Committee in both the Senate and Assembly.
  2. 719-A (Pretlow)/ S.4600-A (Libous) – a bill that would expand on a bill enacted in 2012, and would allow podiatrists to diagnose, treat, operate or prescribe for cutaneous conditions of the ankle up to the level of the knee. It does not have to be a wound that is “contiguous with”, but only has to be “related to” a condition of the foot or ankle.  It would eliminate the requirement for direct supervision of podiatrists training to do this additional work, and also would allow them to basically train themselves.  This bill is in the Higher Education Committee in the Senate and Assembly.
  3. 7035 (Perry)/ S.4917 (LaValle) – a bill that would license naturopaths and create a scope of practice for them that could be interpreted in many ways, and is not clear as to their limits of practice. It would allow them to practice as primary care providers, call themselves naturopathic doctors, claims that they cannot do invasive procedures, yet allows them to immunize and perform cryotherapy.  This bill remains in the Higher Education Committee in the Senate and Assembly.
  4. 2063 (Libous)/ A.2803 (Paulin) – a bill that would authorize optometrists to use and prescribe various oral therapeutic drugs, which have a systemic effect on the body, which they are not trained to deal with. Most of the requested drugs are rarely, if ever, used by ophthalmologists, and are unnecessary for optometrists to use.  This bill is in the Higher Education Committee in the Senate and Assembly.
  5. 215-A (Martins)/ A.4391 (O’Donnell) – a bill to permit chiropractors to form LLCs with physicians as partners. This bill could allow chiropractors, who own a controlling interest in the LLC to tell employed physicians, or even a minority partner, how to practice and what tests to conduct.  This bill passed the Senate, and remains in the Higher Education Committee in the Assembly.
  6. 5824 (Lanza) – a bill that would provide for the certification of psychologists to prescribe drugs. This bill is in the Senate Higher Education Committee.  There is no same-as bill in the Assembly.

The bills that have passed both Houses were vigorously negotiated by MSSNY to make them more acceptable to medicine.  
(ELLMAN, DEARS)


BILL REQUIRING EDUCATION OF ATHLETES REGARDING SUDDEN CARDIAC ARREST PASSES NYS ASSEMBLY; PENDING IN SENATE RULES COMMITTEE
Assembly Bill 8107/Senate Bill 5984, sponsored by Assemblymember Michael Cusick and Senator Andrew Lanza, has passed the NYS Assembly.  Its companion measure is pending in the Senate Rules Committee.   The legislation would require that the New York State Department of Health to develop an educational brochure on preventing sudden cardiac arrest among student athletes.  Under the bill’s provisions, the NYS Commissioner of Health shall provide educational materials for students and their parents and guardians regarding sudden cardiac arrest.  The Medical Society of the State of New York supports this measure and worked with the sponsors to help develop this legislation. The bill also calls for this material to be developed in conjunction with the Commissioner of Education, the Medical Society of the State of New York, the New York Chapter of the American Academy of Pediatrics, and the American Heart Association. The brochure would include an explanation of sudden cardiac arrest, a description of early warning signs, and an overview of options that are privately available for screening. The State of New Jersey currently has a program where brochures are sent home to parents and guardians. This legislation would establish a similar program by developing brochures that could be given to parents as well as pediatricians to distribute.

Sudden cardiac death is the result of an unexpected failure of proper heart function, usually (about 60% of the time) during or immediately after exercise without trauma. Since the heart stops pumping adequately, the athlete quickly collapses, loses consciousness, and ultimately dies unless normal heart rhythm is restored using an automated external defibrillator (AED). About 100 such deaths are reported in the United States per year. According to the American College of Cardiology, the chance of sudden death occurring to any individual high school athlete is about one in 200,000 per year. Sudden cardiac death is more common: in males than in females; in football and basketball than in other sports; and in African-Americans than in other races and ethnic groups. It remains important that athletes, parents, coaches and the health care community are educated about the issue of sudden cardiac arrest and the importance of recognizing the early warning signs and be provided with information about available screening options.   Additionally, it is important that all school officials and coaches are trained in the use of AEDs and having them available on the athletic field.
(CLANCY, AUSTER)


HEALTHCARE PROFESSIONAL TRANSPARENCY ACT HITS SNAGS DURING LAST WEEK OF SESSION- COMMITTEE CHAIRS AND SPONSORS COMMIT TO WORKING TO RESOLVE ISSUES DURING THE OFF SESSION
Throughout the Session MSSNY has worked closely with several state and national specialty societies including the NYS Society of Anesthesiology and the NYS Society of Dermatology and Dermatologic Surgery, in pursuing legislation (S.4651-C, Griffo/A.7129-D, Stirpe) to assure that health care professionals are appropriately identified in their one-on-one interaction with patients and in their advertisements to the public. Specifically, the bill would require that advertisements for services to be provided by health care practitioners identify the type of professional license held by the health care professional.  In addition, this measure would require all advertisements to be free from any and all deceptive or misleading information.  Ambiguous provider nomenclature, related advertisements and marketing, and the myriad of individuals one encounters in each point of service exacerbate patient uncertainty.  Further, patient autonomy and decision-making are jeopardized by uncertainty and misunderstanding in the health care patient-provider relationship.  Importantly, this measure would have also required health care practitioners to wear an identification name tag during all patient encounters that includes the type of license held by the practitioner.

While the bill advanced to the floor of the Senate and was placed on an Assembly Committee agenda, changes were proposed to the Assembly bill which could not be embraced. Of concern is the issue of whether practitioners should be subject to professional misconduct in all instances where they fail to wear the identification badges. The Chair of the Assembly Higher Education Committee and the sponsors of the legislation have agreed to work with the physician community to address these concerns.
 (DEARS, ELLMAN) 


US HOUSE TO CONSIDER IPAB REPEAL LEGISLATION NEXT WEEK
Legislation is expected to be voted on next week by the U.S. House of Representatives to repeal the Independent Payment Advisory Board (HR 1190, Roe) enacted as part of the ACA.   Among the 235 co-sponsors of the IPAB repeal legislation are New York Congressional delegation members Chris Collins, Peter King, Sean Patrick Maloney, Chris Gibson, Tom Reed, Elise Stefanik, Richard Hanna and John Katko.  Physicians are urged to contact their Respective member of the US House of Representatives in support of this legislation.  To find contact information for your respective House member, please go to MSSNY’s Physician Action Center here.

The IPAB is charged with making recommendations to cut Medicare expenditures if spending growth reaches an arbitrary level that can only be overturned by a supermajority of Congress.  MSSNY recently signed on to a patient and provider advocacy letter  in support of repeal of the IPAB.  The letter notes that “The Independent Payment Advisory Board (IPAB), a provision of the Patient Protection and Affordable Care Act (PPACA), not only poses a threat to that access but also, once activated, will shift healthcare costs to consumers in the private sector and infringe upon the decision making responsibilities and prerogatives of the Congress. We request your support to repeal IPAB.”
(AUSTER)           


MSSNY JOINS OTHER STATE MEDICAL SOCIETIES TO URGE 2-YEAR ICD-10 TRANSITION PERIOD
MSSNY joined the medical associations of California, Florida and Texas in writing to CMS Acting Director Andy Slavitt to urge a two-year ICD-10 “grace period” when physicians and other health care providers are required to use ICD-10 codes starting October 1, 2015.   At its recent meeting, physician delegates to the AMA House of Delegates overwhelmingly called upon the AMA to seek such 2-year “grace period”.  The letter notes that “the Oct. 1 mandatory implementation of the ICD-10-CM coding system is a looming disaster. The results of the recent end-to-end tests give us little confidence that the nation’s physicians, electronic health records, claims clearinghouses, commercial insurance companies, and government agencies will be ready when we “throw the switch” to ICD-10.”

Specifically, the letter asks that CMS implement the following steps with regard to ICD-10 implementation:

  • A two-year period during which physicians will not be penalized for errors, mistakes, and/or malfunctions of the system;
  • A two-year period in which physicians will not be subject to RAC audits related to ICD-10 coding mistakes;
  • A two-year period during which physician payments will not be reduced or withheld based on ICD-10 coding mistakes; and
  • Advanced payments in the event that claims are delayed.
    (AUSTER)


CME WEBINARS ON PTSD AND TBI IN RETURNING VETERANS

MSSNY will be offering two CME webinars on the topic of “PTSD and TBI In Returning Veterans:  Identification and Treatment.”

June 24, 2015, 7:00 – 8:00 AM

Faculty:  Frank Dowling, MD

Registration:

June 30, 2015, 6:00 – 7:00 PM

Faculty:  Joshua Cohen, MD

Registration:

Course Objectives:

  • Explain the two most common disorders facing returning veterans today, their prevalence, risks, costs, and comorbidities.
  • Identify common symptoms and causes of PTSD and Traumatic Brain Injury (TBI), especially those that affect returning veterans most.
  • Outline proven treatment options in psychotherapy and pharmacotherapy, from concept to implementation.
  • Outline the process of recovery and post-traumatic growth.
  • Discuss barriers to treatment, including those unique to military culture, and how to overcome them.

The sessions are sponsored by MSSNY through a grant offered by the NYS Office of Mental Hygiene.

Program flyer can be accessed here:

For more information, contact Greg Elperin at gelperin@mssny.org or (518) 465-8085.

(DEARS, ELPERIN, HARDIN) 


FINAL “ADVOCACY MATTERS” SESSION ON SHIN-NY PATIENT LOOK-UP
The final “Advocacy Matters” CME webinar on the topic “SHIN-NY Statewide Patient Record Look-Up,” co-sponsored by MSSNY in conjunction with the New York Chapter of the American College of Physicians (NYACP) and the New York eHealth Collaborative (NYeC), will be held on June 24, 2015, from 6-7 PM.  The faculty will include David Whitlinger, CEO of NYeC, Inez Sieben, NYeC COO,   Lisa Halperin Fleischer, NYeC CMO, and Paul Wilder, NYeC CIO.

Course objectives:

  • Provide an update and overview of the Statewide Healthcare Information Network of New York (SHIN-NY) and its value to healthcare providers
  • Give Healthcare Providers Information on how they will be able to access and share patient records through the SHIN-NY
  • Provide an overview of what capabilities will be available for healthcare providers this year and what they may already be able to access.

Registration link is below:

June 24, 2015 (6-7 PM):   Register here

Flyer is available here:

Information sheet on the Data Exchange Incentive Program is available here:

For more information, contact Miriam Hardin at mhardin@mssny.org  or (518) 465-8085.                                                                                                          (DEARS, HARDIN)

For more information relating to any of the above articles, please contact the appropriate contributing staff member at the following email addresses:       

pschuh@mssny.org ldears@mssny.org   mauster@mssny.org  
pclancy@mssny.org bellman@mssny.org    

 

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Council Notes from June 18 Meeting

  • Dr. Thomas Madejski was elected to the AMA’s Council on Medical Service at the June AMA Meeting in Chicago.
  • Dr. John Kennedy has been named Chair of the AMA Delegation with Dr. Charles Rothberg as Vice-Chair.
  • Dr. Sellers presented the MSSNYPAC report, which included information about the possibility of procuring data to enrich the PAC database.  The data would be used as a tool for increased contributions. MSSNYPAC has a mobile donate site at www.mssny.org/mobile and active Facebook and Twitter accounts.
  • The Medical, Educational, and Scientific Foundation of New York (MESF) reported the following:
    • MESF has completed The Essentials of Leadership: What They Didn’t Teach You in Medical School program, which was presented by Rick Popovic to 13 county medical societies and other organizations. The total attendee count was nearly 400.
    • As a follow-up to the basic Leadership Training Program, MESF has responded to an RFP from the Physicians Foundation and has submitted an application for funding for additional leadership training programs. The grant application is for $150,000 for a two year program.
    • MESF has held discussions with Johns Hopkins in Baltimore for the development of a series of two year online programs on various Internal Medicine topics. The approach will permit efficient use of Johns Hopkins faculty time while taking advantage of readily available medical writers in India.


NY Workers Comp Business Re-Engineering Project (BPR) Roadshow Series
The BPR team has scheduled its next series of roadshows. The roadshow sessions will provide an update on current BPR initiatives and talk about what is planned for Phase 2. Here is the agenda: Programmatic Updates; Medical Authorization Portal; Payor Compliance; and BPR Phase 2: New Initiatives to Come

The full schedule is listed below.

District Office
Brooklyn 111 Livingston Street
19th Floor, Room 1917
Brooklyn, NY 11201
6/23/15 12:00 pm
4:00 pm
Manhattan 215 West 125th Street
Room 509-511
New York, NY 10027
6/24/15 12:00 pm
4:00 pm
White Plains 75 South Broadway
White Plains, NY 10601
6/30/15 12:00 pm
Queens 168-46 91st Avenue
3rd Floor, Room 325
Jamaica, NY 11432
7/1/15 12:00 pm
4:00 pm
Hauppauge 220 East Rabro Drive
Board Room 116-H
Hauppauge, NY 11788
7/2/15 12:00 pm
4:00 pm
Buffalo Ellicott Square Building
295 Main Street
Suite 400, Room 438
Buffalo, NY 14203
7/7/15 12:00 pm
4:00 pm
Rochester 130 Main Street West
Basement Conference Room
Rochester, NY 14614
7/8/15 12:00 pm
4:00 pm

These sessions offer an opportunity for stakeholders to learn about what is happening on the BPR project directly from the BPR team leaders. They also have become an important means of direct communication with their stakeholders. The team looks forward to addressing questions and exchanging ideas. Please email bpr@wcb.ny.gov with any questions.


Many Seniors Treated in ED after Car Crash on Pain Meds Six Months Later
Many seniors injured in motor vehicle crashes remain in pain for months afterwards, negatively affecting their quality of life and ability to live independently, according to a study published in Annals of Emergency Medicine available here.

The study looked at patients aged 65 and older who visited one of eight emergency departments after a motor vehicle crash between June 2011 and 2014 and were discharged home after evaluation. More than half of the patients were still taking some type of pain reliever after six months and about 10% had become daily users of opioid pain relievers, the study found. Of patients with persistent moderate to severe pain, 73% had experienced a decline in their physical function and 23% had experienced a change in living situation to obtain additional help. “The types of injuries that younger people recover from relatively quickly seem to put many seniors into a negative spiral of pain and disability,” said lead author Timothy Platts-Mills, M.D. “Older adults are an important subgroup of individuals injured by motor vehicle crashes and their numbers are expected to double over the next two decades.”


OPRA Prescription Reminders for Unlicensed/Foreign Residents and Interns
In December 2013, New York State (NYS) Medicaid issued a Special Edition (Vol.29, No.13) of the Medicaid Update to provide enrollment requirements and guidance for all Ordering, Prescribing, Referring, and Attending (OPRA) servicing/billing providers.

The purpose of this article is to provide a reminder regarding OPRA prescription requirements for unlicensed residents, interns and foreign physicians in training.

  • NYS Medicaid recognizes prescriptions written by providers legally authorized to prescribe per NYS Education Law Article 131 Section 6526 and 10NYCRR 80.75(e). This includes unlicensed residents, interns and foreign physicians in training programs, under the supervision of a NY State Medicaid enrolled physician.
  • In accordance with NYS Education Law, NYS Medicaid does NOT require the name and signature of the supervising physician to be included on the prescription. However, in order to enable billing by the dispensing pharmacy, prescriptions written by unlicensed residents must include the NPI of the supervising/ attending physician who is enrolled in Medicaid (see last bullet point below regarding billing requirements).
  • NYS Medicaid only enrolls licensed providers. As a result, unlicensed residents, interns or foreign physicians in training programs are not eligible for enrollment as NYS Medicaid providers.
  • Effective January 2014, NYS Fee-For-Service (FFS) Medicaid implemented claims editing that enforced the OPRA requirement for healthcare professionals, practice managers, facility administrators, and servicing/billing providers. Therefore, pharmacy claims for services ordered by unlicensed residents, interns and foreign physicians in training programs reject when initially submitted for payment. The following two (2) options continue to be available to pharmacies, to enable payment:
    1. Resubmit the claim, using the National Provider Identifier (NPI) of the enrolled NYS Medicaid provider (the intern or resident’s supervising physician).
    2. In the event the NPI number of the supervising physician cannot be obtained – or – the pharmacy’s billing system is limited to submitting only one prescriber NPI number then use the urgent/emergency override option (outlined below).


Ask the HPV Experts: CDC Experts Answer Your Questions
The questions and answers in this edition of IAC Express, all related to human papillomavirus (HPV) vaccination, first appeared in the May 2015 issue of Needle Tips.
The questions are answered by experts, medical officer Andrew T. Kroger, MD, MPH; and nurse educator Donna L. Weaver, RN, MN. Both are with the National Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention (CDC).


Narcotic Addicts Can Sue Doctors and Pharmacies for “Enabling” Them
In a 3-2 decision, the Supreme Court of West Virginia ruled that narcotic addicts may sue pharmacies and physicians for facilitating their addictions. A suit was brought on behalf of 29 pain center patients who had been treated with narcotics for various injuries and became addicted. One article quoted the Chief Justice’s explanation: “A plaintiff’s wrongful or immoral conduct does not prohibit them from seeking damages as the result of the actions of others.”

The court recognized that most of the plaintiffs “admitted their abuse of controlled substances occurred before they sought help “at the pain clinic. In a dissenting opinion, one justice wrote that the decision “requires hardworking West Virginians to immerse themselves in the sordid details of the parties’ enterprise in an attempt to determine who is the least culpable—a drug addict or his dealer.”

In response to the ruling, the West Virginia Medical Association issued a statement: “It may cause some physicians to curb or stop treating pain altogether for fear of retribution should treatment lead to patient addiction and/or criminal behavior. It may create additional barriers for patients seeking treatment for legitimate chronic pain due to reduced access to physicians. It would allow criminals to potentially profit for their wrongful conduct by taking doctors and pharmacists to court.”

A post on the American Pharmacists Association website explained that pharmacists were included in the ruling “because they were aware of the ‘pill mill’ activities of the medical providers. The plaintiffs said these pharmacies refilled the controlled substances too early, refilled them for excessive periods of time, filled contraindicated controlled substances, and filled ‘synergistic’ controlled substances.”



Classifieds

Board Eligible Plastic Surgeon Seeks Full Time Position

Brookdale University Hospital Attending Emeritus is resuming practice after retirement. 20 years private practice experience in cosmetic, reconstructive and hand surgery. Plastic Surgery Board Eligible. Seeks full time position with NYS group; flexible salary, will relocate. 6 month on the job preceptorship required to activate NY Medical license. Please email fredricjcohenmd@aol.com.

Dr. Cohen

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

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