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There was an offensive and one-sided article, featuring an insurance industry viewpoint on out-of-network issues, published in the March 7 issue of Crain’s New York Business titled “3 Specialties Yield Most ‘Surprise Medical Bills.’ If you have not read it, I would like to bring it to your attention here.
The full text of the letter that MSSNY sent to Crains previously that was the basis for Dr. Hughes’ quote in their article this week follows below.
To the Editor:
It is outrageous for the multi-billion dollar profit generating health insurance industry to portray themselves as being “gamed” (“Doctors Gaming the System?, Crain’s’ Health Pulse, 2/9/12) when the reality is that the insurers have been “gaming” the out of network coverage system for years.
While we at MSSNY do not have any specific knowledge of the circumstances articulated in this article, we were disappointed the article did not discuss a frequent contributing factor to out of network coverage issues – the health insurers’ ongoing efforts to mislead policyholders regarding the extent of their coverage for out of network health care.
The problem is long-standing. When he was Attorney General, Governor Andrew Cuomo required health insurers to discontinue the use of the flawed Ingenix database for determining payments for out of network services. It was determined that the database, maintained by a wholly owned subsidiary of United Healthcare, was for many years being manipulated in order to produce much higher out of pocket costs to patients by significantly under-reimbursing providers for out of network care.
Despite the toppling of the Ingenix database, some companies have made this problem even worse by using seriously misleading methodologies for determining out-of-network payments— such as a percentage of the severely inadequate Medicare fee schedule. These policies deceptively appear to adequately cover costs, but, in fact, they result in grossly insufficient payments from insurers. Remarkably, these methodologies result in far less coverage than when the insurance companies were using the discredited Ingenix database that Governor Cuomo helped topple when he was Attorney General!
In this regard, MSSNY is seeking the enactment of the legislation (A.7489, Gottfried/S.5068, Hannon) to require health insurance companies to re-align their methodology for paying for out of network care so that it is based upon the independent FAIR Health database. The legislation would enable patients to easily understand and anticipate the out of pocket costs they might face for a particular treatment. Importantly, it would also enable employers shopping for health insurance coverage to easily compare the scope of coverage for each product by requiring insurers to provide examples of the anticipated costs of frequently provided out of network health care services.
The health plans should look to address why some physicians - a relative few - choose to not participate with these plans in the first place. These factors include inappropriate care denials; time-consuming pre-authorization hassles; woefully insufficient and delayed reimbursement, and aggressive auditing practices that threaten to shutter physician offices.
We must protect patients and employers from being sold insurance products that might appear to provide adequate coverage, but in fact leave the consumer/patient significantly uninsured.
We agree that legislation and regulatory action are needed, but any efforts in this regard should be directed to address the health plan abuses that are limiting patient care and grossly increase patient out of pocket costs while enriching the companies’ bottom lines.
Robert Hughes, MD
President-Elect, Medical Society of the State of New York
MSSNY’S LOBBY DAY (MARCH 19 AND 20) APPROACHES; LIST OF VIDEO-VENUES GROWING- LINK TO CONFERENCE FROM HOME
MSSNY’s Legislative Day will take place on March 19 and 20 with two components. An Open Forum will be held the evening of March 19and lobby visits with legislators on March 20. The Open Forum through web-conferencing is scheduled for 5:30 PM - 7:30PM. Robert Easton, Executive Deputy Superintendent for Insurance; Troy Oechsner, Deputy Superintendent for Health, Department of Financial Services and Jason Helgerson, Medicaid Director and Deputy Commissioner for the office of Health Insurance Programs will speak and take questions from 5:30 – 6:15 pm. Senator Kemp Hannon and Assemblyman Richard Gottfried, the Chairs respectively of the Senate and Assembly Health Committees; and Senator James Seward and Assemblyman Joseph Morelle, the Chairs respectively of the Senate and Assembly Insurance Committees will appear on a panel from 6:15 – 7:30 pm. Live and remote attendees are encouraged to supply questions for our guests to MSSNY in advance. Dr. Cohen and Dr. Geraci-Ciardullo, MSSNY’s Speaker and Vice-Speaker, will ask the questions and moderate the discussion.
(Please note, until the evening of March 19th, the video from last year’s event will be displayed.)
If you would like to ask a question, please send it in advance to the following address:
Physicians who do not attend the session in Albany are encouraged to attend in their local communities. A list of venues appears below and is growing. In addition, individual physicians can connect directly to the videoconference. If you so desire, please contact Liz Dears at firstname.lastname@example.org to assure that you will receive the contact information for direct connection to the March 19 event.
On Tuesday morning March 20, MSSNY Staff will provide a briefing for Physician Advocates who attend this session in Albany in person. The briefing will deal with the proposed State Budget, Medical Liability, Managed Care, Scope of Practice, and important Public Health issues. These meetings will be held at the Hotel Albany (formerly the Crowne Plaza Hotel) in Downtown Albany. At the conclusion of the briefing, Physician Advocates may walk to the Capitol Building only a couple blocks away for visits with their local legislators that are to be arranged by your County Medical Society.
47 New Scotland Avenue
Albany, NY 12208
65 Pennsylvania Avenue, Suite 201
Binghamton, NY 13903-1607
The office of Phillip C Gioia, MD,
37 W Garden St, 203
Auburn, NY 13021
Dr. Phillip Gioia
315 253 6257
1 Civic Center Plaza, Suite 541
Poughkeepsie NY 12601
New York County
Touro College of Osteopathic Medicine (TouroCOM)
230 West 125th Street
New York, NY
Susan Y. Tucker
Phone 212-684-4670, ext. 212
St. Charles Hospital
Wisdom Conference Center
200 Belle Terre Road
Port Jefferson, N.Y. 11777
Contact: Serafina Genova
Brookhaven Memorial Hospital
Conference Trailer A & B
101 Hospital Rd
Patchogue, N.Y. 11772
Contact: Shelly Albrechtsen
Westchester County Medical Society
Westchester Academy of Medicine
333 Westchester Avenue, Suite LN01
White Plains, NY 10604
(DIVISION OF GOVERNMENTAL AFFAIRS)
DFS RELEASES REPORT ON SURPRISE MEDICAL BILLS; CALLS FOR GREATER TRANSPARENCY BY HEALTH INSURERS, HOSPITALS AND PHYSICIANS
Department of Financial Services (DFS) Superintendent Benjamin Lawsky held a press conference this week to release a report and outline several steps to address the issue of medical bills to consumers from out of network providers. The report contains a series of recommendations, including some items for which MSSNY has advocated but others which will necessitate much closer examination. While the Superintendent discussed advancing legislation for consideration by the State Legislature consistent with the report, no such legislation has yet been specifically released. Superintendent Lawsky indicated he would be working with stakeholders, including physicians, to develop the legislation. MSSNY Division of Governmental Affairs (DGA) staff has had numerous meetings with DFS on many of the matters addressed in the report. Indeed, MSSNY DGA staff met with top staff at DFS this week to further discuss the Department’s proposals.
Specifically, the report noted that “there are competing interests in crafting solutions to these problems. New rules aimed at addressing these issues should recognize the right of providers to remain out of network, and should avoid placing undue burdens that could interfere with patient care or deter specialists from providing emergency care or other needed services.”
Importantly, the report and accompanying press release (available by clicking here:
http://www.dfs.ny.gov/about/press/pr1203071.htm) extensively highlighted the problems that consumers now face as a result of “insurers moving to a system that greatly increases how much it costs consumers when they are treated out of network.” In this regard, the report urges a requirement for insurers to describe how their reimbursement methodology compares to actual UCR costs for medical services, and to inform consumers of the anticipated out of pocket costs they will face for particular out of network medical services, based upon the difference between the insurer’s coverage methodology and what is the actual UCR. To address the problem of plans offering flimsy out of network coverage, the report also recommends a requirement that health plan policies that provide coverage for out of network medical care meet a minimum threshold of coverage. Both of these principles are consistent with the Hannon-Gottfried legislation (A.7489-B/S.5068-A) which is one of MSSNY’s top priorities for this legislative session. Moreover, to reduce the instances when out of network disputes can arise, the report includes a recommendation to extend statutory network adequacy protections to Exclusive Provider or Preferred Provider Organizations that are now only applicable to HMOs.
Not surprisingly, given the recent heightened attention in Crains and other media publications across the State, the report includes recommendations relative to “surprise” non-emergency bills and alleged “excessive” non-par emergency care bills. The report highlights that unexpected out of network bills are one of the most common complaints received by DFS. The report includes recommendations that, in non-emergency situations for care provided in health care facilities, providers should disclose whether or not all services are in-network before such services are provided and how much they will charge. Health plans should also be required to disclose how much the plan will cover for scheduled medical care that may include an out of network provider.
Moreover, the report highlighted several examples of emergency room care provided by non-participating physicians where the bills submitted were several hundred times above the applicable Medicare rate. DFS recommended that excessive fees for non-par emergency room care be prohibited, and an independent process be established to determine whether a fee is, in fact, “excessive”. The report did not define what is “excessive”. MSSNY has for the last decade proactively and successfully fought aggressive lobbying efforts by the HMO industry to establish a default rate in these non-par ER billing disputes. MSSNY has supported the creation of an independent dispute resolution process that can be used to address situations where there truly may have been excessive billing (not “excessive” as defined by the health plan) in a way that will not impact the overwhelming majority of physicians who are seeking to be paid fairly for care they are legal obligated to provide in an emergency.
MSSNY Division of Governmental Affairs will keep all physicians informed of all ongoing discussions.
(AUSTER, CONWAY, DEARS)
SCOPE OF PRACTICE BILLS REPORTED IN SENATE
Three bills of great concern to organized medicine were reported this week from the Senate Higher Education Committee:
The first bill, S.3758-A (Libous)/A.9293 (Pretlow), would expand the scope of practice of podiatrists beyond the treatment of the foot and, in doing so, remove language that restricted podiatrists from treating other parts of the body. MSSNY has consistently opposed the bill. It was reported to the Senate Finance Committee. To send a letter of opposition please click HERE.
The second bill, S.3059-A (Libous), would permit oral and maxillofacial surgeons (dental surgeons) to perform surgical procedures well beyond their current scope of practice. The “additional surgical procedures” which they could perform include but are not limited to rhinoplasty (nose jobs), bletharoplasty (eyelid surgery), rhytidectomy (face lift), submental liposuction, otoplasty (ear surgery), dermabrasion, and other procedures of the head and neck. MSSNY has opposed this bill for many years. The bill was reported to the Senate Finance Committee. To send a letter of opposition please click HERE.
The third bill, S.5012-B (Fuschillo)/ A.7403-B (V. Lopez), would, among other things, allow doctors of chiropractic to form partnerships with medical doctors. MSSNY opposes this bill and has indicated that there is no reason for a multidisciplinary partnership including physicians and non-physicians, and that it could be potentially detrimental to patient health. This bill was reported to the Senate Floor, where it could be voted on at any time. To send a letter of opposition please click HERE.
Physicians are urged to contact your Senator to oppose these bills at 518-455-2800. (ELLMAN, DEARS)
PHYSICIAN ACTION NEEDED ON PRESCRIPTION DRUG LEGISLATION; PATIENT ADVOCACY GROUPS EXPRESS CONCERNS
The Medical Society continues to meet with legislators to express its strong concerns with the I-STOP legislation (A.8320/S.5720). This legislation would create a new prescription drug monitoring database called I-STOP and would require physicians or their staff to check the database prior to writing of any controlled substance prescription and enter the prescription information into the database. Significant penalties would be imposed for failure to comply. MSSNY believes that the I-STOP legislation could cause significant delays in patients receiving necessary pain medications. MSSNY has also discussed its concerns with staff from the governor’s office and state health department officials and has proposed solutions to enhancing the existing database. Physicians from MSSNY Addiction and Psychiatric Medicine Committee have been working closely with the state Health Department’s Bureau of Narcotics Enforcement on methods to expand the current prescription monitoring database. Patient advocacy organizations, such as the US Pain Foundation, the American Cancer Society and the Center for Medical Consumers, have expressed strong concerns or opposition to this legislation and have indicated that this measure would have “a chilling effect” on patients receiving needed pain medication. Physicians are urged to send a MSSNY Grassroots Action Center letter to legislators expressing opposition the I-STOP legislation. Physicians can send a letter from the MSSNY Grassroots Action Center by clicking here: http://www.capwiz.com/mssny/issues/alert/?alertid=60937971&type=ST.
(CLANCY, DEARS, AUSTER, CONWAY)
BUDGET NEGOTIATIONS PROGRESS
MSSNY representatives continue meeting with key legislators and staff on budget issues as the April 1st deadline approaches. Earlier Capital Updates have reported on the budget issues of particular concern to physicians. (See Vol 24, No 6). In particular, MSSNY continues to meet with all interested parties on changes to the Excess Insurance Program which were contained within the Executive Budget. MSSNY has urged that all physicians currently eligible for the additional liability protections remain eligible.
(CONWAY, AUSTER, DEARS)
IPAB REPEAL LEGISLATION CLEARS COMMITTEE VOTES AND HEADS TO HOUSE FLOOR
The House Ways and Means Committee yesterday approved by a voice vote legislation (HR 452) that would repeal the Independent Payment Advisory Board (IPAB). The House Energy and Commerce Committee earlier this week approved the same bill. The bill now heads for consideration by the full House. The bill has 234 co-sponsors from both parties, including New York Representatives:
- Tim Bishop (D-Suffolk County);
- Anne Marie Buerkle (R-Cayuga, Monroe, Onondaga & Wayne Counties);
- Chris Gibson (R-Columbia, Delaware, Dutchess, Essex, Greene, Otsego, Rensselaer, Saratoga, Washington, and Warren counties);
- Michael Grimm (R-Richmond & Kings Counties);
- Dr. Nan Hayworth (R-Putnam, Dutchess, Orange, Westchester and Rockland counties)
- Peter King (R-Nassau and Suffolk Counties)
- Tom Reed (R-Allegany, Cattaraugus, Chemung, Monroe, Ontario, Schuyler, Steuben and Yates counties)
Repeal of the IPAB is strongly supported by MSSNY and the federation of medicine including the AMA. MSSNY recently joined several state medical societies and national medical specialty societies in a letter to Congressional leaders urging its repeal. The purpose of the IPAB, a component of the federal health care reform law, is to make recommendations to Congress to cut Medicare spending and payments starting in 2015. Particularly problematic is the requirement that the recommendations of the IPAB will go into effect unless a supermajority of Congress enacts legislation to prevent such cuts, a task which likely will be extremely difficult. This would give the unelected members of IPAB extraordinary powers to reduce Medicare payments.
To preserve seniors’ access to care under the Medicare program, we need reforms that will result in adjustments to Medicare payments that keep pace with the rapidly rising cost of running a medical practice, not laws which will result in unfair cuts. Physicians can send a letter to support HR 452 by clicking here: http://capwiz.com/mssny/issues/alert/?alertid=51206511&type=CO (AUSTER)
AMA LAUNCHES GRASSROOTS CAMPAIGN FOR SUPPORT FOR MEDICARE PATIENT EMPOWERMENT ACT
The AMA has launched a grassroots initiative to generate public support for Congressional passage of H.R. 1700 and S. 1042, the Medicare Patient Empowerment Act (MPEA), introduced by Rep. Tom Price (R-Ga.) and Sen. Lisa Murkowski (R-Ark.), respectively. This legislation will create a new Medicare option to allow patients and physicians to enter into private contract arrangements without penalties for either party. The grassroots effort is focused on securing House and Senate cosponsors for the bills. MSSNY President Paul Hamlin, MD and MSSNY staff recently participated in a meeting convened by the AMA of select state medical and national specialty medical associations to preview the educational material and offer suggestions for improvements.
A range of resource material has been developed to support these grassroots efforts, including:
- An educational slide deck, with script, for physician audiences that can be personalized by the presenter
- A physician-focused frequently asked questions document
- An educational slide deck, with script, for patient audiences that can be personalized by the presenter
- A patient-focused frequently asked questions document
- A short educational video for patients
- A downloadable patient flier for physician offices
- A web-based petition for patients and physicians, which provides access to educational material and enables patients to send email directly to their legislators.
This can be accessed through a dedicated site: www.MyMedicare-MyChoice.org, which can also be linked from the MSSNY website at www.mssny.org. Physicians can also send a letter to our Senators and Representatives by clicking HERE!
A patient brochure for distribution in physician offices is also being finalized. According to the AMA, copies will be available later this month, free of charge, in batches of 50 for physicians who order them through the My Medicare-My Choice site. (AUSTER)
DOH ADDS NAVIGATION AIDS ON WEBSITE TO ASSIST DOCTORS ACROSS NEW YORK APPLICATION PROCESS
The Department of Health has announced that they have added new documents to the NYS Department of Health website to assist physicians in navigating the Doctors Across New York Practice Support and Loan Repayment application process.
The application deadline for both programs is 3/30/12. (ELLMAN)
MID-DAY MEDICAL MATTERS CME WEBINAR TO BE HELD WEDNESDAY
Adult Immunizations is the topic for the next Mid-Day Medical Matters webinar held on Wednesday, March 21, 2012 from 12:30-1:30 p.m. The educational objectives for this CME webinar are: summarize adult immunizations recommended by the Advisory Committee on Immunizations Practice (ACIP), outline strategies to assist physicians in implementing ACIP recommendations, and explore potential barriers that exist for physicians in providing adult immunizations. William Valenti, MD will serve as faculty. Dr. Valenti is an internist/infectious diseases specialist and is a co-founder of Community Health Network, a not-for-profit medical clinic/disease management program caring for 700 people with HIV/AIDS in Rochester, NY. A graduate of the Medical College of Wisconsin, Dr. Valenti did his infectious diseases training at the University of Rochester and is Clinical Associate Professor of Medicine at the University Of Rochester School Of Medicine. He is chair of the Medical Society’s Infectious Diseases Committee and a member of the Medical Society’s Committee on Emergency Preparedness and Bioterrorism/Terrorism Response.
Mid-Day Medical Matters is a series of Continuing Medical Education webinars held on the third Wednesday of every month from 12:30-1:30 p.m. and will run until June 2012. MSSNY has accredited each webinar for 1 AMA PRA Category 1 Creditä. Each webinar is free to physicians, but seating is limited.
To register for any or all of the webinars please click HERE. For additional information contact Stacey Grinnell at email@example.com or by calling 518-465-8085. (CLANCY, GRINNELL)
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The New Medicare Physician Fee Schedule
On Wednesday, February 22, 2012, President Obama signed into law the Middle Class Tax Relief and Job Creation Act of 2012 (Job Creation Act). This new law prevents a scheduled payment cut for physicians and other practitioners who treat Medicare patients from taking effect on March 1, 2012.
Section 3003 - Physician Payment Update - The new law extends the current zero percent update for claims with dates of service on or after March 1, 2012, through December 31, 2012. However, the new law does not extend Sections 307 and 309 of the Continuation Act, the five percent physician fee schedule mental health add-on payment and the special 2011 payment rates for bone mass measurement, respectively. The Centers for Medicare & Medicaid Services (CMS) is currently revising the 2012 Medicare Physician Fee Schedule (MPFS) to reflect the expiration of both of these provisions. In order to allow sufficient time to develop, test, and implement the revised MPFS, Medicare claims administration contractors may hold mental health and bone density claims with March 2012 dates of service for up to 10 business days. We expect these claims to be released into processing no later than March 15, 2012. Other March 2012 claims will be unaffected by this claim hold.
The new Medicare Physician Fee Schedule for NY can be found here.
Primer on Medical Audits Now Available from PAI
A very helpful document on recovery audits courtesy of the Physicians Advocacy Institute (PAI) was recently published. The PAI was created pursuant to one of the national health insurance company legal settlements. The Institute’s mission is two fold— to ensure company compliance with each legal settlement and to provide our physicians with the tools that they need to conduct business with health insurers on a level playing field. The Medical Society of the State of New York is a founding PAI Board member. MSSNY’s CEO Rick Abrams represented MSSNY on the Board for the last six years. MSSNY’s legal counsel, Donald Moy, Esq., serves on the Institute’s Compliance Committee who oversaw the crafting of this document.
Problems with 5010 Transition? The AMA Wants to Know
The AMA would like to know if you are having significant problems or continuing to experience (i.e. major cash flow / claims processing interruptions, or inability to resolve problems with payers and clearinghouses) during this transition. He AMA would like physicians to report problems to them as soon as possible so that they can communicate these to CMS and so it can be determined what further steps will be needed to allow all physicians to begin sending and receiving claims and other transactions successfully without interruption using the new standard.The AMA would like to be informed before COB on Monday. Therefore, if you are, or you are aware of any other physicians, having difficulties with their 5010 transition, please let them know ASAP
The AMA continues to encourage physicians to submit complaints using their complaint form here and for all other payers click here.
Adolescent Vaccines Need Better PR
Few adolescents and parents know that the HPV, Tdap, and MenACWY vaccines all are recommended for adolescents. Vaccination rates for U.S. adolescents have improved but still lag behind rates for children. Using data from the 2007 HealthStyles and YouthStyles consumer mail surveys, investigators analyzed the knowledge and attitudes of 1087 adolescents (age range, 11–18 years) and 1208 parents regarding three vaccines for teenagers: human papillomavirus (HPV) vaccine, Tdap (for tetanus, diphtheria, and pertussis), and MenACWY (meningococcal conjugate vaccine). Survey responses were weighted to represent the demographic makeup of the general U.S. population.
The table lists the percentages of parents and adolescents who said that they were aware of the various recommendations. One third of parents and 43% of adolescents strongly agreed or agreed with the statement "I have concerns about the safety of recommended adolescent vaccines." However, 84% of parents and 91% of adolescents agreed that getting vaccinated is one way to protect their own or their child’s health. Furthermore, 84% of adolescents strongly agreed or agreed that they would get a vaccine if recommended by their healthcare provider.
eMeasure Implementation: Implications in Small Practice Settings
On March 15 from 12:30 to 2:00 PM EST, join the National Quality Forum’s eMeasure Learning Collaborative for a free webinar titled “eMeasure Implementation: Implications in Small Practice Settings.” NQF staff and eMeasure experts from the provider and implementer community will lead an interactive 90-minute webinar and open discussion. This free webinar is open to the public and intended to provide information related to eMeasure implementation within small practices (e.g., physicians, private practices, and clinics). Register here.
Who Should Attend
· Small practice providers planning to implement eMeasures in the near future or longer term