July 21, 2003

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Medicare Reform Conferees Begin Work; Much at Stake for Beneficiaries and Physicians Alike
Although it is now likely that the House/Senate conference on the Medicare Reform bill will extend into the fall, the work did begin with an organizational meeting last week. In addition to dealing with the potential of prescription drug coverage, the conference will also hopefully resolve favorably the Medicare physician fee schedule fix, Without a fix, the payment schedule will decline by 4% in January. The House version of the reform bill did replace the cut with a positive update of at least 1.5% for the next two years. However, without Senate action, the provision cannot take effect.
       The Maine Medical Association was disappointed that Maine Senator Olympia Snowe was not named one of the Senate conferees.  Sen. Snowe would have been an important supporter of changes in the geographical indices that discriminate against rural physicians.  Senate Finance Committee Chair Charles Grassley (R-Iowa) has been a strong supporter of the goals of the GEM (Geographical Equity in Medicare) Coalition and hopefully his presence on the Conference Committee will assist in bringing about needed reform in the area of geographic disparities.

     Other Senate conferees include Majority Leader and Doctor William Frist, Don Nickles (R-Okla.), Orrin Hatch (R-Utah), Jon Kyle (R-Ariz.), Max Baucus (D-Mont.), Jay Rockefeller (D-W. Va.) Tom Daschle (D-S.D.) and John Breaux (D. La).  House conferees include Ways and Means Chair Bill Thomas (R-Calif.), and Health Subcommittee Chair Nancy Johnson (R-Conn.), Energy and Commerce Chair Billy Tauzin (R-La), Subcommittee Chair Michael Bilirakis (R-Fla.), House Majority Leader Tom DeLay (R-Texas), Reps. John Dingell (D-Mich.), Charles Rangel (D-N.Y.), and Marion Berry (D-Ark.).

      Differences in the House bill and Senate bill are very significant and there are both significant technical issues and philosophical issues to be worked out before passage of a compromise can be obtained.  And each party seems to be drawing a line in the sand, rather than looking for compromise.  Senator Ted Kennedy and 28 other Democratic Senators recently wrote to President Bush indicating that they would oppose any conference report that failed to address six fundamental issues, with many of these issues threatening to derail genuine reform.  Seventy-five Republican House members wrote the President to remind him of some commitments made in the State of the Union message wherein the President said, " We will not deny, we will not ignore, we will not pass along our problems to other COngresses, to other Presidents, and other generations."

     As the House bill passed by a mere one-vote margin, the President can not afford to lose any GOP votes.  On the other hand, if Senate Democrats threaten a filibuster, the prospect of Medicare reform in this Congress would look bleak.  MMA will continue to keep you posted on the progress of the Conference Commiittee deliberations.

Maine Health Access Foundation Announces 2003 Major Grant Awards
     The Maine Health Access Foundation on July 16th announced its granting of nearly $2.5 million for various projects around the state.  A total of eighteen projects were funded from a pool of 154 applications.  The majority of grants, fourteen, to be exact, went to projects that address the needs of patient groups in Maine deemed to be most vulnerable, including the uninsured, the terminally ill, Mainers living in rural areas and immigrant populations..

     In these 2003 grants, the Foundation's Board tried to find projects that attempted to make long-term changes to the state's health-care system and Board officials indicated that this criterion would be relied upon heavily in the future grant process.  This represents a significant change from last year when the Foundation awarded $3.7 million to 36 projects that mainly offered immediate fixes to pressing health care needs such as the provision of dental services to the low-income Mainers.

     Slightly less than a third of the monies awarded this year is going to projects aimed at preventing mental illness in young persons and improving access to mental health services. especially to children.

     The Foundation was established with funds from the sale of Blue Cross Blue Shield of Maine to Anthem, Inc.  It currently has assets of approximately $85 million.   MMA's President-elect Maroulla Gleaton, M.D., an ophthalmologist practicing in Augusta serves as a member of the Foundation Board.  The Board's Executive Director is Dr. Wendy Wolf, who is also an MMA member.  A complete list of the grants awarded is available from MMA (622-3374) and is on the Foundation website at www.mehaf.org. [return to top]

Changes Coming in MaineCare Eligibility Verification Process
The MaineCare program will be converting to a credit or debit-type "swipe" card some time in the coming year.  The new cards will have no eligibility information printed on them so participating providers will have to use the Bureau of Medical Services' telephone verification system or obtain from the State's contractor, the card-reading terminal.

The State has awarded to Medifax-EDI, Inc. a contract for the production and distribution of the swipe cards and the provision of a number of electronic eligibility verification products.  The MaineCare swipe card will replace the current monthly MaineCare eligibility form.  Each eligible MaineCare member will have their own card instead of the current practice of issuing one eligibility form per household with all eligible members listed on it. 

Medifax-EDI, Inc. offers point-of-service systems using a credit card-like terminal, PC software, and internet member eligibility verification products.  In addition, the new MaineCare claims processing system (MECMS) will offer a web-based component and the voice response system will be upgraded.  Both of these can be used to verify member eligibility.  Medifax soon will be sending out marketing materials describing each of their products.  Also, the Medifax marketing staff will be available to conduct in person, on site demonstrations of their products.

The State's contract with Medifax caps the amount the company can charge providers for eligibility verification transactions because Medifax is the single source for these products.  Participating providers who currently have contracts with other vendors for the provision of electronic health plan member eligibility verification will be able to access this MaineCare eligibility data.  The State's contract specifies that Medifax will provide this data to other vendors who have contracts with providers.


The Bureau of Medical Services has asked for physician feedback on the implementation schedule for this new swipe card.  Should the Bureau proceed with implementation now or wait until the MECMS claims processing system comes on line, probably in February or March 2004?  See the related note about the MECMS implementation schedule and HIPAA compliance.

Please provide any feedback you may have to Gordon Smith, gsmith@mainemed.com, or Andrew MacLean, amaclean@mainemed.com.


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MaineCare Claims Processing System to Miss HIPAA Deadline
The Bureau of Medical Services recently has advised MMA that the new MaineCare claims processing system (MECMS) will not be prepared to accept claims meeting the HIPAA transactions and code sets rule standards on October 16, 2003.  MECMS now is expected to come on line in February or March, 2004.  The Bureau urges practices to continue submitting claims electronically in the current format rather than changing to paper.  The Bureau will continue to accept electronic claims that are not HIPAA compliant for the foreseable future, even after MECMS is operational. [return to top]

Anticipate MaineCare "Self-Audit" Letter Soon
The Bureau of Medical Services, Surveillance and Utilization Review Unit soon will mail all MaineCare participating providers a letter encouraging them to perform internal audits and to return overpayments voluntarily.  The letter will include a simplified reimbursement form for reporting identified overpayments.

This recommendation is consistent with the U.S. Department of Health & Human Services OIG's compliance rule that includes 7 elements.

 The Seven Basic Compliance Program Elements


The OIG encourages physicians to view a compliance program as analogous to practicing preventive medicine.  As proposed for other sectors of the health care industry, the OIG has identified 7 basic compliance program elements:


  • A clear commitment to compliance:  establishing compliance standards through the development of a code of conduct and written policies and procedures;

  • Appointment of a trustworthy compliance officer with a high level of responsibility:  assigning compliance monitoring efforts to a designated compliance officer or contact;

  • Effective training and education programs:  conducting comprehensive training and education on practice ethics and policies and procedures;

  • Auditing and monitoring:  conducting internal monitoring and auditing focusing on high-risk billing and coding issues through performance of periodic audits;

  • Communications:  developing accessible lines of communication, such as discussions at staff meetings regarding fraudulent or erroneous conduct issues and community bulletin boards, to keep practice employees updated regarding compliance activities;

  • Internal investigation and enforcement:  enforcing disciplinary standards by making clear or ensuring employees are aware that compliance is treated seriously and that violations will be dealt with consistently and uniformly; and

  • Response to identified offenses and application of corrective action initiatives:  responding appropriately to detected violations through the investigation of allegations and the disclosure of incidents to appropriate government entities.

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An Invitation to Offer Feedback on Draft Electronic Health Record Standards
The American Medical Association, in collaboration with a number of other key healthcare stakeholder organizations, is sponsoring a series of open forum meetings across the country in August.  These forums, for which there is no charge to participate, will serve as your opportunity to provide input into fast-moving advances toward the development of a functional model and standards for the electronic health record (EHR). 

On July 1 of this year, Secretary of Health and Human Services (DHHS) Tommy Thompson announced that the Department has asked two organizations, the Institute of Medicine and Health Level 7 (HL7), to design a standard for electronic health records (EHR).  This fast-tracked project is to report to DHHS by Sept. 1, 2003.  The model and standards will be used in demonstration projects in the coming year and will have far reaching impact on the entire health care community, ranging from large enterprises to individual practices.

The open forum meetings are designed to gather feedback on the EHR  model and standards being developed by HL7 before they are delivered to DHHS.  The agenda for the forums will include an overview of the draft HL7 model and its implications and will provide an opportunity for gathering comment.  Participant feedback will be compiled in a summary report for HL7 and DHHS.  A copy of the report will also be available for public review.

The forum closest to Maine will be held on Monday, August 18 at the Massachusetts Medical Society in Waltham, MA. Again, there is no charge for participation, but you need to register at www.EHRCollaborative.org.  Questions can be directed to either Clair Callan, M.D. at clair_callan@ama-assn.org or Tom Murray at thomas_murray@ama-assn.org. [return to top]

Justice Dept. Asks Supreme Court to Review Marijuana Prescribing
In early July, seeking to allow federal authorities to revoke the federal prescription licenses of physicians who recommend marijuana to patients, Justice Department attorneys asked the U.S. Supreme Court to review a medical marijuana case that the 9th  Circuit Court of Appeals in San Francisco decided last October.  In the appeals court decision, a three-judge panel unanimously voted that the federal government could neither investigate physicians wno recommend marijuana use to ill patients nor revoke their licenses.  Chief Judge Mary Schroeder, who wrote the court's opinion, rejected the government's argument that Proposition 215 - the California  law that allows patients to use marijuana with a doctor's recommendation - subverts federal illegal drug use prevention efforts.  She said that punishing doctors who recommend medical marijuana "effectively prohibited candid discussions between doctors and patients, in violation of the First Amendment." Schroeder also said that the federal policy violated states' traditional authority over the practice of medicine.  The court panel, however, maintained that prescribing marijuana, as opposed to recommending it, is illegal.  If the Supreme Court accepts the case and reverses the appellate court's decision, it would override states' marijuana laws, including Maine's. [return to top]

Cassidy Assumes Chair of Maine Hospital Association
Jim Cassidy, CEO of St. Mary's Regional Medical Center, was installed as chair of the Maine Hospital Association's Board of Directors during MHA's recent Summer Forum in Rockport.  Cassidy succeeds John Welsh, CEO of Rumford Hospital.  Welsh will continue on MHA's Board of DIrectors as immediate past chair.

Cassidy has been president and CEO of Sisters of Charity Health System Inc. and of St. Mary's Regional Medical Center since 1991 and previously was president of the Southwestern Vermont Medical Center in Bennington, Vt. [return to top]

Discussion of Merger of DHS and DHDS Begins
The Advisory Council for the Reorganization and Unification of the Department of Human Services and the Department of Behavioral and Developmental Services met on July 10th.  Valerie Landry, former State Labor Commissioner, chairs the 12-member council that has been charged with creating the "blueprint" to combine and streamline the two departments.  The council will work toward the four goals established by the Governor:  improving services to the people of Maine, increasing management efficiency, solidifying partnerships with community organizations and increasing fiscal accountability and efficiencies.

The Council adopted a schedule that will lead to detailed legislation to implement the merger being introduced into the next session of the Legislature, which will convene in January of 2004.

The Council will meet monthly and has established various subcommittees to focus on specific programs, services and operations.  Richard Batt, President of the Franklin Community Health Network is one of the few Council members with a background in healthcare.  MMA staff will monitor the work of the Council.  For more information, contact either Gordon Smith, Andy MacLean or Anna Bragdon at MMA.  (gsmith@mainemed.com; amaclean@mainemed.com; abragdon@mainemed.com

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For more information or to contact us directly, please visit www.mainemed.com l ©2003, Maine Medical Association