Advice from MLMIC Regarding Physician’s ISTOP Obligations
What is the obligation of physicians to continue to write prescriptions for controlled substances after I-STOP goes into effect?
There is no “obligation” per se upon a physician to write a prescription for a controlled substance. Indeed, many physicians throughout the state believe that chronic pain is best managed by a pain management specialist and decline to provide prescriptions for controlled substances. The decision as to whether the patient requires a prescription for a controlled substance is a treatment decision inherent in the physician-patient relationship. If there are valid reasons why a patient requires a controlled substance, then the physician must either prescribe the appropriate medication, or refer the patient to another provider or specialist who will meet the patient’s treatment needs. The referral, however, must be realistic. In other words, the referring provider must have a reasonable belief that the specialist will indeed accept the patient and will give the patient an appointment in a timely manner. In many parts of the state, the wait to be seen in a pain clinic could take weeks or even months. During the interim, the referring physician should handle whatever the patient requires for pain control in order to avoid any potential claim of negligence or abandonment. This could include prescriptions for controlled substances, or non-narcotic forms of pain management.
If there comes a point in the physician patient relationship where the provider is no longer comfortable writing prescriptions for controlled substances (which have previously been written for the patient), then there would be an obligation once again to refer the patient to a pain management specialist. It is our recommendation that during the interim, the physician should continue whatever medication is necessary for the patient’s treatment needs. If it is possible, the patient may be weaned off the controlled substance with appropriate instructions, interim dosages, or perhaps non-narcotic treatments for pain.
As a best practice, it would be advisable for the referring physician’s office to arrange the appointment with the pain management specialist. In this way, the physician can be certain that the patient’s treatment needs will be met in a timely manner. Whether the patient keeps the appointment is entirely up to the patient. If the patient does not keep the appointment, then the physician may continue to treat the patient making it clear that narcotics will not be prescribed, may wean the patient off the controlled substance, or may discharge the patient for non-compliance (assuming the patient’s clinical condition is stable). Unless the patient is weaned during the discharge period, the physician should continue any prescriptions which have previously been provided.
It is strongly recommended that physicians require patients to sign a pain management contract as a condition of receiving controlled substance prescriptions for chronic pain. If the physician learns that the patient is receiving controlled substance prescriptions from other sources, this would be a reason to either discontinue writing prescriptions and/or discharge the patient from care.
Frances A. Ciardullo, Esq.
Fager & Amsler, LLP
Counsel to Medical Liability Mutual Insurance Company, Inc.
I-STOP IMPLEMENTATION WEBINAR NOW AVAILABLE FOR PHYSICIANS; OBTAIN CME CREDIT
The Medical Society of the State of New York (MSSNY) archived webinar on I-STOP Implementation is now available to physicians and other health care providers as a continuing educational program. The archived I-Stop Implementation webinar has been accredited for 1.0 AMA PRA Category 1 CreditsTM.
Terence O’Leary, Director of the Bureau of Narcotic Enforcement from the NYS Department of Health, is the featured speaker. Registration for the archived I-STOP Implementation webinar is required and is free for MSSNY members with their MSSNY identification number. There is a fee of $100 for non-members, which can be applied towards a MSSNY membership.
Educational objectives for the program are: 1) Discuss the implementation of I-STOP and how it will affect your practice; 2) Explain the changes being made to the prescription drug database and how those changes will enhance the information contained in the database and how access to the database will be made easier for those checking it; 3) Define the issues under consideration by the Work Group on Prescription Pain Medication Awareness and how resolution of these issues will affect physicians and the patients they serve and 4) Define the rules being implemented to support the e-prescribing mandate and how e-prescribing systems will interface with the prescription drug database.
Following the viewing of the webinar there is a certification quiz and evaluation that physicians and other health care providers will need to take in order to receive the CME credit. These materials will need to be emailed or faxed back to MSSNY.
Registration is required and physicians can log in here.
Further information on this program may be obtained by contacting Pat Clancy, Vice President for Public Health and Education at firstname.lastname@example.org.
PHYSICIANS DUTY TO CONSULT THE PRESCRIPTION MONITORING PROGRAM IS REQUIRED ON TUESDAY, AUGUST 27, 2013
The “duty to consult” the Prescription Monitoring Program (PMP) is effective on Tuesday, August 27, 2013 and requires prescribers to review a patients’ prescription history prior to issuing a prescription for Schedule II, III or IV drug.
You have submitted an application for a Health Commerce System (HCS) but have not yet received approval or a password to reactivate your account. Can I still prescribe for patients on August 27, 2013?
DOH realizes that there is a backlog. The Department of Health has put in considerable resources to working with the Health Commerce System (HCS) staff. The NYS Bureau of Narcotic Enforcement (BNE) has paid for a number of temporary employees and staff members to handle the backlog. A large part of the backlog has been addressed and accounts are being processed at a faster rate.
Anyone who has made good faith efforts to apply for a HCS account, but has not yet received approval or a password; the NYS Bureau of Narcotic Enforcement (BNE) is not asking that person to avoid the treatment of their patients. BNE will not carve out a waiver period. However, before BNE seeks enforcement, BNE will know if you tried to apply. You will need to be able to document that you submitted an application, made phone calls, etc. As long as you are making reasonable efforts to obtain your HCS account and continue to do so, please continue to treat your patients. If possible, have a prescriber who already has an account in your practice and access the PMP until you receive your account.
If you have an established Health Commerce System (HCS) account; follow these directions to access the Prescription Monitoring Program (PMP) Registry on August 27, 2013
To access the Prescription Monitoring Program (PMP) registry go to the Health Commerce System at:
2) Log onto the system with your user ID and password (If you can’t remember your password, call the Commerce Account Management Unit at 1-866-529-1890, Option 1 for assistance).
3) Select “Applications” at the top of the page. Click on the letter “P”.
4) Scroll down to the Prescription Monitoring Program Registry.
5) Click the green plus sign under the Add/Remove column to add this application to your “Favorites” so you don’t have to scroll down each time in the HCS (optional).
6) Click to open the program.
7) Enter all required information.
8) Review the Frequently Asked Questions with the application for further information.
Should you or your designee encounter technological difficulties or have questions regarding accessing the PMP, please contact the New York State Department of Health Commerce Account Management Unit at 1-866-529-1890, option 1 for assistance or the Bureau of Narcotic Enforcement at 1-866-811-7957.
Don’t have a Health Commerce System (HCS) account? Steps to begin registration:
Physicians and their selected designees who have not yet established an account should begin the process immediately as you cannot access the PMP registry without an account. To obtain an account please go to the New York State website at:
2) Click on Apply for an HCS Medical Professions account to apply for a Health Commerce System (HCS) account for prescribing and non-prescribing medical professionals.
Please go to the MSSNY website for step by step instruction on how to establish a Health Commerce System account at www.mssny.org. The process to obtain an HCS account takes about two weeks.
Would you like to designate your office staff to look up patients? If your answer to this question is YES, please read the following:
Physicians can designate office staff to look up patients but the designee must also have a HCS account. They can sign up by following the instructions above. Once the designee has an HCS account, the physician will need to designate them in the PMP. Physicians will need to log onto the PMP and click on the blue tab that says designate. Physicians then can list the names of their designees. Designees may begin to look up patients since the regulations were adopted on August 21, 2013.
Physicians and staff are also encouraged to go the NYS DOH Bureau of Narcotic Enforcement’s website for additional information:
Do you have a Health Commerce Account but haven’t used it within the past ninety days and need a new password? Read below:
Passwords expire after 90 days, therefore, if you have not used your account in the last 90 days, your password will have expired. To reestablish your password, contact the New York State Department of Health Commerce Account Management Unit (CAMU) at 1-866-529-1890.
NYS Commerce Account Management Unit- hours of operation:
The Department of Health has indicated that the CAMU unit will be open until August 27, 2013 from 8 a.m. to 7 p.m. and will be open this weekend from 9 a.m. to 12 noon to provide assistance to physicians who are seeking to set up an HCS account or to obtain a password for existing accounts. Physicians can call the CAMU at 1-866-529-1890. DOH has indicated that that the physician himself or herself must be on the phone --administrative staff is not authorized to establish an HCS Account or reactivate an account on behalf of a physician.
MSSNY recommends that all physicians begin documenting their calls to the CAMU unit, the length of time on the phone, etc., and maintain these records as MSSNY has been informed that there is a backlog.
What if I don’t comply with the law?
Failure to comply with the law may result in fines, jail time and loss of licensure.
Frequently Asked Questions for NYS PMP and Drug Schedule
The Department of Health Prescription Monitoring Program contains a list of frequently asked questions (FAQs) concerning the PMP and the Schedule for II, III or IV drugs. Physicians and their designees can access this directly from the PMP or the FAQs and schedule for drugs is also available on the MSSNY website at www.mssny.org.
Who established the “duty to consult” requirement?
The “duty to consult” requirement was the result of the passage of a law in 2012 called ISTOP. Chapter 447 of the Laws of 2012 amended Public Health Law Article 33, the New York State Controlled Substances Act, and requires most practitioners in New York State to check New York's Prescription Monitoring Program (PMP) Registry prior to prescribing a controlled substance in Schedules II, III, and IV. This law requires prescribers to review information in the PMP database on their patients’ prescription history. The law also requires pharmacists to enter the prescription into a database called the Prescription Monitoring Program (PMP). Pharmacies have the obligation under the law to enter the prescription into the database within 24 hours.
The law also requires e-prescribing of all prescriptions, including controlled substances, by March 27, 2015. Please check the MSSNY website periodically for any future updates on this law.
Supreme Court Takes Control of LICH from SUNY Downstate
In a jaw-dropping turn of events, a Supreme Court judge in Brooklyn issued an order Tuesday that yanks control of troubled Long Island College Hospital away from state-owned SUNY Downstate. The same judge, Caroyn Demarest, had placed the Brooklyn hospital under SUNY's stewardship in May 2011 but ruled Tuesday that SUNY had not operated LICH in good faith. The decision suggests that LICH could be placed under the care of a court-approved receiver. [Crain's New York Business]
AMA presses CMS on pending claims issue
Physicians are expressing concern that they may be liable for the cost of care for patients receiving premium support and insurance under the Health Insurance Exchanges (Marketplaces) when they fail to pay their premiums. Under the Affordable Care Act (ACA), patients have a 90-day grace period to catch up on paying delinquent premiums. During the first 30 days of this period, plans are required to continue paying claims; but during the subsequent 60 days plans may designate claims as pending and ultimately deny payments if premiums are not paid. In that event, physicians must try to collect the entire payment from the patient. While plans are required to notify physicians “as soon as practicable” when a patient has entered such a grace period, the Centers for Medicare and Medicaid Services (CMS) left it up to plans to determine how and when such notification is given. Physicians need real-time information about patient eligibility status, and for the past few months the AMA has been discussing the issue with senior administration officials. The administration seems to understand our concerns, and we will continue to work toward a solution.
Prepare for Upcoming CMS Physician Quality Reporting System (PQRS) Program Milestones
Providers considered eligible and able to participate in the Centers for Medicare & Medicaid Services (CMS) Physician Quality Reporting System (PQRS) may be subject to a payment adjustment beginning in 2015. Eligible professionals (EPs) that do not report data on quality measures for covered professional services during the 2013 program year will be subject to a 1.5% payment adjustment beginning in 2015.
Below are important dates to guide successful participation in PQRS.
October 15, 2013
- Last day for individuals and groups participating in the Group Practice Reporting Option (GPRO) to elect to participate in the administrative claims-based reporting mechanism to avoid a payment adjustment in 2015
- Last day for groups to register to participate in GPRO for the 2013 PQRS program year via Web Interface or registry reporting
- Helpful Resources:
December 31, 2013
- Milestone: Reporting for the 2013 PQRS program year ends for both group practices and individuals
- Helpful Resources:
February 28, 2014
- Last day to submit 2013 PQRS data through some reporting methods (deadline for submission of PQRS data varies by reporting method, but all methods require data to be submitted by end of first quarter in 2014)
- Last day to submit CQMs for the PQRS-Medicare EHR Incentive Pilot Reporting Pilot Program
- Last day that 2013 claims will be processed to be counted for PQRS reporting
- Helpful Resources:
For more information about PQRS, visit the CMS PQRS website. You can also learn about other eHealth initiatives at CMS by visiting the CMS eHealth website
US Travelers Warned of Cholera in Cuba
People should take precautions when traveling to or residing in Cuba after reports of cholera in Havana and eastern Cuba, the U.S. State Department said in a security warning on Tuesday.
The primary risk factor is eating or drinking contaminated food or water. Potential sources of infection include unsterilized water, street vendor food, raw fish dishes like ceviche, and steamed shellfish.
U.S. State Department security alert
Merrill Lynch Mortgages: New MSSNY Member Benefit
Merrill Lynch is proud to welcome The Medical Society of the State of New York (MSSNY) to its corporate rewards program for mortgages. MSSNY-verified members can now receive thousands of dollars of savings in closing cost discounts for personal mortgages just like their counterparts at Fortune 500 companies. For mortgages over $417,000, Merrill Lynch will provide a 0.50 % closing cost discount (for a mortgage of $1 million, a closing cost discount of $5,000 = $1,000,000 x 0.005%). Read More