Legislation Introduced re Unfair RAC Audit – May 28, 2015 –

Dr. Joseph R. Maldonado
MSSNY President
May 28, 2015
Weekly Update for New York State Physicians
Volume 16, Number 20
Christina Cronin Southard, Editor
Julie Vecchione DeSimone, Assistant Editor
mssnye-news@mssny.org  www.mssny.org


Representative George Holding of North Carolina recently introduced legislation (HR 2568) entitled “The Fair Medical Audits Act of 2015.” This legislation reflects several MSSNY-supported provisions and addresses many concerns that physicians have with regard to the extraordinary lack of transparency and expensive, time-consuming and often unfair processes that plague the current Medicare audit program.

Currently, Medicare pays recovery audit contractors or “RACs” on a contingency basis to find overpayments to health care providers, providing these contractors with undue monetary incentives to audit doctors. The five regional firms contracted by the government are paid up to 12.5 percent of all claims they successfully identify as invalid. The burden this places on physicians from both a resource, financial liability and record-keeping standpoint is significant, as the RAC auditors can go back as far as three years.

This legislation would establish incentives for RACs to make more accurate audit findings and increase educational efforts to help physicians avoid common mistakes.  Since 2006, MSSNY has worked closely with the Physicians Advocacy Institute to advocate for more fair and transparent medical audits.

It is time to address fundamental problems that have contributed to the backlog of audit appeals and caused a great deal of unnecessary expense and confusion for physicians in New York. We commend Congressman Holding for his leadership on this critically important issue. Rep. Holding is a member of the House Ways and Means Subcommittee on Health, which has jurisdiction to consider legislation to reform the RAC program.

MSSNY has contacted each of the members of New York’s Congressional delegation to urge them to co-sponsor this important legislation, and we urge you contact your local Representative as well.

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

Please send your comments to comments@mssny.org



All physicians must contact their respective Assemblymembers to urge that they oppose legislation (A.285, Weinstein/S.911, Libous) that would drastically increase medical liability premiums by changing the medical liability Statute of limitations to a “Date of Discovery” rule.  The bill will be considered by the Assembly Codes Committee at its Tuesday, June 2 meeting.  The letter can be sent here:   http://cqrcengage.com/mssny/app/write-a-letter?1&engagementId=105729.  Physicians are also encouraged to contact individual members of the NYS Assembly Codes Committee to express their opposition to this one-sided disastrous legislation.   A list of the members with links to their contact information is provided here: http://assembly.state.ny.us/comm/?sec=mem&id=7.  As New York physicians continue to pay liability premiums that are among the very highest in the country and face reduced payments from Medicare and commercial insurers, as well as rapidly increasing overhead costs to remain in practice, no liability increases can be tolerated.

List of members of the Assembly Codes Committee:

Joseph Lentol, Chair(AD 50)         518-455-4477            718-383-7474

Robin Schimminger (AD 140)        518-455-4767            716-873-2540

Helene Weinstein    (AD 41)          518-455-5462            718-648-4700

James Brennan       (AD 44)          518-455-5377            718-788-7221

Keith Wright              (AD 70)         518-455-4793            212-866-5809

Gary Pretlow             (AD 89)         518-455-5291            914-667-0127

Vivian Cook              (AD 32)          518-455-4203           718-322-3975

Steven Cymbrowitz (AD 45)           518-455-5214            718-743-4078

Michele Titus            (AD 31)          518-455-5668            718-327-1845

Daniel O’Donnell     (AD 69)           518-455-5603            212-866-3970

Charles Lavine         (AD 13)          518-455-5456            516-676-0050

Nick Perry                  (AD 58)        518-455-4166            718-385-3336

Kenneth Zebrowski (AD 96)           518-455-5735            845-634-1091

Thomas Abinati        (AD 92)          518-455-5753            914-631-1605

David Weprin            (AD 24)          518-455-5806           718-454-3027

Walter Mosley           (AD 57)          518-455-5325           718-596-0100

Alfred Graf                 (AD 100)       518-455-5355           845-794-5807

Joseph Giglio           (AD 148)         518-455-5241           716-373-7103

Thomas McKevitt     (AD 17)           518-455-5341           516-228-4960

Michael Montesano (AD 15)            518-455-4684            516-937-3571

Edward Ra                (AD 19)          518-455-4627           516-535-4095

ClaudiaTenney        (AD 101)         518-455-5334            315-736-3879



Earlier this week, by a vote of 92-52, the NYS Assembly passed Assemblyman Gottfried’s Single Payer bill (A.5062/S.3525). Click on the here to see how your Assembly representative voted on the bill.

Well in advance of this vote, MSSNY sent its respectful letter of opposition to Assemblyman Gottfried and the entire NYS Assembly

All sources have indicated to MSSNY representatives that this is a one-house bill which will not be taken up by the NYS Senate.  See article here wherein the passage of the bill was characterized  as a “largely symbolic step toward universal health insurance.”                        (DEARS, AUSTER)



MSSNY, working closely with several state and national specialty societies including the NYS Society of Anesthesiology and the NYS Society of Dermatology and Dermatologic Surgery, is aggressively pursuing legislation (S.4651-A, Griffo/A.7129-A, 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.  Importantly, this bill will 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 also require health care practitioners to wear an identification name tag during patient encounters that includes the type of license held by the practitioner.  The bill would also require the health care practitioner outside of a general hospital to display a document in his or her office that clearly identifies the type of license that the practitioner holds.

Physicians are encouraged to contact their elected representatives in both houses of the Legislature to ask that the bill be passed this year.                                           (DEARS, ELLMAN)


MSSNY President Dr. Joseph Maldonado this week participated in a press conference with several patient advocacy organizations in support of legislation (A.2834-A/S.3419-A) to permit physicians to have an expeditious method to override a health insurer drug step therapy protocol so that patients can timely receive the medications best able to treat their particular conditions.   Assembly Health Committee Chair Richard Gottfried and Assembly bill sponsor Matthew Titone also participated in the press conference.  The event garnered significant media coverage from across the state, including quotes from Dr. Maldonado in Crains’ Health Pulse and the Albany CBS Affiliate.  Meetings were held with key legislative leaders thereafter.  The bill is currently before the Assembly and Senate Insurance Committees.  All physicians are urged to express their support for this legislation by sending an e-mail from MSSNY’s Grassroots Action Center.     (AUSTER, DEARS)


Legislation that would require physicians to take three hours of continuing education on pain management, palliative care, and addiction is now on the floor of both houses in the New York State Legislature and can be voted on at any time. Senate Bill 4348 passed out of the Senate Health Committee and has gone to the Senate floor.  Its companion measure, Assembly Bill 355, is also pending on the Assembly floor.   Immediate physician action is needed to stop this measure from passing.  Physicians are urged to send a letter urging defeat of this measure.

Assembly Bill 355, sponsored by Assemblywoman Linda Rosenthal and Senate Bill 4348, sponsored by Senator Kemp Hannon would require three hours of course work every two years for physicians and other healthcare workers.   Under the bill’s provisions, the course work would include each of 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.  MSSNY remains oppose to the measure.                 (CLANCY, DEARS)


Assembly Bill 791B and Senate Bill 4324, sponsored by Assemblywoman Aileen Gunther and Senator Kemp Hannon, were advanced from the Assembly and Senate Health committees this week.  Assembly Bill 791B will now go the Assembly Codes Committee and Senate Bill 4324 will go to the Senate floor for a vote. The Medical Society of the State of New York has been working with a number of provider and patient advocacy organizations in support of this legislation and is urging physicians and their patients to advocate in support of legislation requiring school-based immunizations against the meningococcal disease.  Assembly Bill 791B/Senate Bill 4324 would require that every person entering seventh grade and 11th  grade shall have been immunized against meningococcal disease.   Physicians are encouraged to go to MSSNY’s Grassroots Action Center to send a letter to their legislators and urge support of this bill.

MSSNY has also developed a patient support letter that patients can use to urge support of this legislation.

This bill is consistent with the Advisory Committee on Immunization Practices.  Meningococcal disease is caused by bacteria and is a leading cause of bacterial meningitis.  The bacteria are spread through the exchange of nose and throat droplets, coughing, sneezing or kissing.  Young people, between the ages of 10-25 years of age, are most at risk for this disease.   If not treated quickly, it can lead within hours to death or to permanent damage to the brain and other parts of the body.  Organizations in support of this measure include 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)

STANDARDIZING PRESCRIPTION PRIOR AUTHORIZATION LEGISLATION ADVANCESLegislation to standardize the processes for insurer-required prior authorization of prescription medications is advancing in the New York State Legislature.  This week, legislation (S.4721, Hannon) supported by MSSNY to require the New York State DFS and DOH to develop a standardized form for requesting prior authorization for prescription medications was reported from the Senate Health Committee to the Senate floor.  Similar legislation (A.6983-A, McDonald) is before the full Assembly.  However, the Assembly bill was amended this week.  Instead of requiring the development of a uniform prior authorization form, the Assembly bill has been broadened to require DFS and DOH to develop “standards for prior authorization requests of prescription medications to be utilized by all health care plans for the purposes of submitting a request for a utilization  review  determination  for  coverage  of prescription  drug  benefits under this article”, including standards developed by the National Council for Prescription Drug Programs (NCPDP).  MSSNY is currently reviewing the amended bill.                         (AUSTER, DEARS)


The Medical Society of the State of New York Committee’s on Preventive Medicine and Family Health and the Committee to Eliminate Health Care Disparities, has develop a patient brochure that physicians can offer within their office.  The patient brochure discusses risks associated with pre-diabetes and diabetes and is available in English and Spanish.  If you would like copies of this brochure, please contact the Medical Society of the State of New York at (518) 465-8085 or email Terri Holmes at tholmes@mssny.org and request copies of the Diabetes brochure.  The development of the brochure was made possible from a grant from AstraZeneca.                                                                                                                                                (CLANCY, ELLMAN)


The next “Advocacy Matters” CME webinar will be held on Tuesday, June 9, 2015, from 12:30 to 1:30 PM.  The faculty will include David Whitlinger, CEO of NYeC, New York e-Health Collaborative (NYeC), Inez Sieben, COO, and Lisa Halperin Fleischer, NYeC CMO, presenting on the topic “SHIN-NY Statewide Patient Record Look-Up.”


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.

To register for this webinar, click here and fill out registration form.  (DEARS, HARDIN)


The Medical Society’s final webinar for the spring will be conducted on June 9, 2015 at 7:30 a.m. William Valenti, MD, chair of MSSNY Infectious Disease Committee will present “Emerging Infections 2015-A look at EV-D68 and Chikungunya”. Physicians are encouraged to register by clicking on https://mssny.webex.com . Click on “Training Center” and then on the “Upcoming” tab to register.

The educational objectives are:

  • Recognize and describe Enterovirus D68 (EV D68)
  • Recall the importance of continued immunizations
  • Recognize symptoms of Chikungunya and describe measures for reporting

Physicians may also contact Melissa Hoffman at mhoffman@mssny.org or at 518-465-8085 to register.

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


It is anticipated that Medical Matters programing for fall/spring 2015-2016 will be announced shortly.                                                                                                                     (CLANCY)

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.or  
pclancy@mssny.org bellman@mssny.org    



Step Therapy or Fail Therapy?

Controversy is heating up over a state bill to limit step therapy, the insurance process that requires patients to try less expensive drugs to treat their conditions before their plans will cover more expensive ones recommended by their doctors. The bill (S.2711-A /A.5214-A) would increase pharmaceutical costs while exposing patients to less proven treatments, said the New York Health Plan Association in a statement Thursday. But Dr. Joseph Maldonado, president of Medical Society of the State of New York, said the measure may cut hospital costs incurred when patients are treated with the wrong medication. “There are many instances in which step therapy is very appropriate, but there are instances when this is the medication the patient needs, and they shouldn’t have to jump through unnecessary hoops to get it,” said Dr. Maldonado, who spoke at an Albany press event yesterday hosted by supporters of the legislation.

HANYS Offers Ready. Set. Code!  ICD-10-CM by Specialty.
This series of coding workshops helps physician practices understand the structure of the International Classification of Disease, Tenth Revision, Clinical Modification (ICD-10-CM) and successfully assign diagnosis codes for their specialty.

These two-hour workshops are being held from 1 to 3 p.m. on multiple dates, and are led by American Health Information Management Association certified ICD-10 trainers.  The registration fee for each workshop is $150.

Specialties are grouped as follows:

  • Workshop 1: Cardiology/Vascular/Respiratory
  • Workshop 2: Orthopedic/Podiatry/Spine
  • Workshop 3: OB-GYN/Pediatrics/Urology
  • Workshop 4: Internal Medicine/Family Practice
  • Workshop 5: General Surgery/Gastro/ENT/Plastic Reconstructive/Colon
  • Workshop 6: Mental Health/Neurology/Neuro Surgery/Ophthalmology

Ready. Set. Code!  ICD-10-CM by Specialty has been approved for two American Academy of Professional Coders continuing education units (CEUs) and is eligible for two American Health Information Management Association CEUs.

Registration is available online or by mail by downloading the program information and registration form. Contact: Terry August 

Boston Children’s Hospital Buys Westchester Physician Group
Children’s and Women’s Physicians of Westchester agreed to be acquired by Boston Children’s Hospital, an unusual deal for New York. The 280-doctor practice, which largely focuses on pediatrics, has offices in New York, New Jersey, and Connecticut. It is based in Valhalla, down the road from Westchester Medical Center and the New York Medical College. Both those institutions also are in negotiations with the Boston hospital, said Dr. Leonard Newman, CWPW’s president. (Crain’s 5/26)

If the deal goes through this summer as projected, CWPW will continue to refer to Maria Fareri Children’s Hospital at Westchester Medical Center and NYMC, where its staff has academic faculty appointments. Boston Children’s affiliate is Harvard Medical School, which does not allow faculty appointments outside Massachusetts.

AG: Alzheimer Drug Namenda Will Be Available for 30 Days after Patent Expires
A federal appeals court has rejected a drug manufacturer’s appeal and affirmed a judge’s order that Actavis PLC keep distributing its widely used Alzheimer’s medication until after its patent expires this summer. New York Attorney General Eric Schneiderman, who sought the order, calls the Court of Appeals ruling a victory for consumers. His office says the drug Namenda should remain on shelves 30 days after the patent expires July 11. He alleged anti-trust and state law violations by Actavis in an effort to push patients to its new patented drug and avoid losses from cheaper generics. Dublin-based Actavis says its new drug Namenda XR—taken once daily instead of twice—is better and demand is growing. 

Too Many Women Who Need Bone Screening Aren’t Getting It
Too few women at high risk for osteoporosis are being tested for the bone-depleting condition, while too many women at low-risk are being screened, a new study suggests.

A team led by Dr. Anna Lee Amarnath of the University of California, Davis, examined the medical records of nearly 51,000 women, aged 40 to 85, living in the Sacramento area.

The researchers looked at whether or not women were getting a dual-energy X-ray absorptiometry (DXA) test, which measures bone mineral density.( Journal of General Internal Medicine, news release, May 19, 2015)

The result: Osteoporosis screening rates jumped sharply at age 50, despite guidelines suggesting that screening only begin at age 65, unless a woman has certain risk factors.

However, the study also found that those risk factors — a small body frame, a history of fractures, or taking medications that could thin bones — had only a slight effect on a woman’s decision to get her bones tested.

Over seven years, more than 42 percent of eligible women aged 65 to 74 were not screened, Amarath’s team found, nor were nearly 57 percent of those older than 75.

However, nearly 46 percent of low-risk women aged 50 to 59 were screened, as were 59 percent of low-risk women aged 60 to 64.

The study was published online May 19 in the Journal of General Internal Medicine.

“DXA screening was underused in women at increased fracture risk, including women aged 65 years and older. Meanwhile, it was common among women at low fracture risk, such as younger women without osteoporosis risk factors,” Amarnath said in a journal news release.

What to do? Reminder notes to doctors and patients might help, one expert said.

“Health systems should invest in developing electronic health records systems that prompt providers at the point-of-care when screening is needed and when it can be postponed,” study senior author Joshua Fenton, an associate professor of family and community medicine at UC Davis, said in the news release. 

Medicine Considers What Defines Professionalism
Physicians take an oath to uphold ethical standards, but rapid changes in the health care system may have begun to blur lines across the practice of medicine. What measures should physicians be held accountable to, and who should regulate the profession?

The May 12 issue of JAMA takes a deep dive into professionalism, including viewpoints from scholars and academic leaders about the responsibility and accountability of medicine to self-govern, self-regulate and ensure the highest degree of professionalism.

Prominent physicians among the authors include AMA Executive Vice President and CEO James L. Madara, MD; Ezekiel J. Emanuel, MD, vice provost for global initiatives and chair of the department of medical ethics and health policy at the University of Pennsylvania; Thomas J. Nasca, MD, CEO of the Accreditation Council for Graduate Medical Education; and Lois Margaret Nora, MD, president and CEO of the American Board of Medical Specialties.

The issue examines the key roles and responsibilities of modern governing and accrediting bodies and of professional organizations and societies. Find out what these entities are doing—and what they should do differently—to enhance self-governance, safeguard self-regulation and foster professionalism. 

On a related note, this month’s issue of the AMA Journal of Ethics tackles this topic. The issue examines where professional boundaries start and stop, and how far physicians may go to assist patients with nonclinical matters. Learn about key areas where establishing boundaries with patients may be challenging and issues outside the patient-physician relationship where boundaries are essential.