October 6, 2003

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Aetna Inc. Latest Health Plan to Announce Acceptance of Noncompliant Claims Oct. 16th
Aetna Inc. has followed the lead of CMS and announced its willingness to accept claims that are noncompliant with the HIPAA-mandated electronic transaction and code sets. The effective date of the HIPAA rule is Oct. 16th.
Aetna Inc. has followed the lead of CMS and announced its willingness to accept claims that are non-compliant with the HIPAA-mandated electronic transaction and code sets.  The effective date of the HIPAA rule is Oct. 16th.  In a letter to the Maine Medical Association dated Oct. 1, 2003, Aetna Chief Medical Officer William C. Popik, M.D., stated that while Aetna is ready for the Oct. 16th compliance date, it also understands that, "the date is causing some concern among health care professionals who fear being out of compliance."  Dr. Popik went on to state;

                        Please be assured that we have contingency plans in place to enable the smooth flow of payments.  Again, we strongly encourage doctors, hospitals and other health care professionals to submit claims electronically; but in the event they cannot, Aetna has the flexibility to accept non-compliant claims.  We also are committed to working collaboratively with doctors and clearinghouses as they take the steps necessary to comply with HIPAA.

Dr. Popik also clarified Aetna's position on electronic claims prescribing, indicating that the company strongly encourages electronic submission of claims, believing that it is in the best interest of all parties.  He noted that physicians who file claims electronically save several days in turnaround time, and also have claims processed with significantly greater accuracy .  However, the company does not MANDATE the submission of electronic claims, either nationally or locally.

The AMA's Top 12 Fictions & Facts About Medical Liability Reform: #7
FICTION #7:  The current medical liability insurance crisis is due to the natural cycle of the insurance market and will correct itself.  Therefore, reforms are unnecessary.

FACT:  Median jury verdicts have skyrocketed in recent years, rising 18.4% for jury awards and 7.4% for settlements per year between 1994 and 2000.  By the year 2000, over half of all medical malpractice claims were for over $1 million, as compared to the period between 1994-1996, when only a third of claims rose to this level.  Moreover, the number of suits filed against physicians over their career has also increased with 99 suits filed per 100 physicians in 1999 up from 78 in 1990.

To suggest that medical liability insurance rates have risen solely because of the insurance "cycle," and not these rapid increases in claims, is illogical.  While insurers most certainly use investment income to offset their claims losses, when the severity of claims costs rises exponentially each year, insurers cannot sustain profitability unless they raise their rates.  The extent of the crisis was evident when the well-financed St. Paul Insurance Company, a multi-line insurer, completely withdrew from the medical liability insurance market, citing lack of profitability as compared with other lines of insurance.  Even with less competition and more pricing power, companies are leaving this unpredictable, unstable line of business.

Eliminating "lottery"-type awards through caps on non-economic damages will stabilize the underlying insurance risk and restore predictability to the medical liability insurance market. [return to top]

MaineCare to Issue New Credit Card-Type "Swipe" ID Cards December 1st

Starting December 1, 2003, MaineCare members will be using a new plastic ID card in lieu of their old paper ones.  DHS is currently in the process of notifying MaineCare members about the change.  You should also be hearing from them regarding this new change.  The cards are intended to be permanent, with a magnetic stripe on the back containing embedded information for that individual member.  Questions about the card can be directed to MaineCare Member Services at 1-800-977-6740. 

Medifax EDI, a company in Nashville, Tennessee, is DHS' contractor for the new system.  You can find more information about the company at its web site, www.medifax.com.  The Regional Vice President for Sales in the Northeast is Wade McKenzie who may be reached at wade.mckenzie@medifax.com or at 1-800-444-4336, ext. 2269.

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Medicare Drug Benefit Conferees Make Progress
Although the Senate is not in session, House and Senate Medicare conferees will continue meeting this week, aiming for their self-imposed October 17, 2003 deadline.  Last week, they reached provisional agreement on the structure of the private plans available to beneficiaries.  Under the provisional agreement, an unlimited number of preferred provider organizations could bid for business in the estimated 10 regions of the country established in the bills.  The Bush Administration had argued that program costs could be contained by limiting the number of PPOs to 3 per region.  Also, the conferees agreed to use a blended benchmark for reimbursement rates, combining the Medicare Advantage payment rates contained in the bills and health plan bids.  A national weighting structure would encourage stability in the benchmarks across the regions.

The group has decided that the Center for Medicare and Medicaid Services (CMS) would run the private plan option rather than a new HHS agency, as the House and Senate bills had proposed.  Finally, the conferees currently are leaning toward the House position on covering the drug costs of Medicare/Medicaid dually-eligible individuals, but not as comprehensively as in the House bill. [return to top]

New Study Finds Malpractice Concerns Vary Across Local Markets
A September 2003 paper published by the Center for Studying Health System Change indicates that the severity of malpractice insurance problems varied across 12 nationally representative communities, with some physicians changing how and where they care for patients.  The paper, Issue Brief No. 68, Medical Malpractice Liability Crisis Meets Markets:  Stress in Unexpected Places, concludes that rather than treat patients in their offices, more physicians are referring patients to emergency departments.  And many physicians, especially those practicing in high-risk specialties, are unwilling to provide emergency department on-call coverage because of malpractice liability concerns.

The Center for Studying Health System Change is a non-profit organization located in Washington, D.C. funded by the Robert Wood Johnson Foundation and affiliated with Mathematica Policy Research, Inc. [return to top]

Connecticut Supreme Court Remands Class Action Against Anthem
In its recent opinion in Collins v. Anthem Health Plans, Inc., No. SC 16900, 9/30/03, the Connecticut Supreme Court remanded to the trial court a lawsuit initiated in 1999 by a group of 16 orthopedic surgeons alleging that the Anthem plan in Connecticut breached their provider agreement in a variety of ways including timely payments and other aspects of contract administration.  The Supreme Court rejected the trial court's certification of class action status in the case for an estimated 7000-8000 physicians who were parties to provider agreements between 1993 and 2001.

The Court ruled that the plaintiffs had met the "commonality" and "typicality" tests of class certification, but it also determined that the trial court had not considered whether questions of law or fact common to the plaintiffs and class members outweighed questions affecting only individuals.  [return to top]

Medicare's New Electronic Billing Requirements Clarified
Most claims submitted to Medicare must be filed electronically beginning Oct. 16th, 2003.  However, there are some important exceptions to the requirement, many of which are applicable to a number of physician practices in Maine.

At this point in time, Medicare (CMA) will automatically waive the requirement for the following:

1.  For small providers, defined as physician practices having less than 10 full-time equivalent employees.

2.  When no method is available for the submission of electronic claims, including:

  • Roster billing of influenza and pneumoccal vaccinations
  • Claims for payment under Medicare demonstration projects
  • Claims where Medicare is the secondary payer to two or more primary payers

3.  In unusual circumstances, defined as follows:

  • Submission of dental claims
  • A service interruption in the mode of submitting the electronic claim that is outside the control of the entity submitting the claim for the period of interruption (e.g., providers with no telephone or communication service)

The requirement does not apply to adjustments or appeals of previously submitted claims. 

Although some providers may have to pay initial costs in order to become compliant - for instance to upgrade computer systems - the Centers for Medicare and Medicaid Services (CMS) expects that the electronic filing requirement will help Medicare improve its efficiency in processing claims and keep Medicare claims processing costs down.  For more information, visit the CMS Web site at www.cms.hhs.gov and click on "Electronic Submission of Medicare Claims Interim Final Rule" under "Headlines." [return to top]

Invitations to Sesquicentennial Gala are in the Mail
Invitations to MMA's Sesquicentennial Gala, to be held Saturday evening, Nov. 8th, in Portland are in the mail.  All MMA members and Corporate Affiliates will receive an invitation.  The event begins with a reception at the Portland Museum of Art at 5:30pm, followed by a program and dinner at the Holiday Inn by the Bay on Spring Street.  By 9:00pm guests will be dancing to the music of the popular Tony Boffa band.

Guests attending will include current AMA President Donald Palmisano, M.D., J.D. and the entire AMA Board of Trustees.  Governor Baldacci and members of the Congressional Delegation are also expected to attend.  A 15 minute video on the history of medicine in Maine has been created for the event.

Information on tickets or available sponsorships may be obtained by contacting Susan Feener or Buell Miller, M.D. at 622-3374 or via e-mail sfeener@mainemed.com, bmiller@mainemed,com.

Over 500 persons are expected to attend so get in your reservations soon.  A block of rooms is available at the Holiday Inn by the Bay for those guests wishing to stay overnight ($99.00). [return to top]

Intranasal Influenza Vaccine (CPT 90660, Flumist) Requires PA for MaineCare Members [Announcement fr
Influenza virus infections cause significant morbidity and mortality in the United States each year.  Prevention of influenza relies primarily on annual vaccination of persons at elevated risk for complications from influenza infection.  Until recently, only inactivated influenza vaccine administered by intramuscular injection was available for use in the United States.

On June 17, 2003, the Food and Drug Administration (FDA) approved an intranasal, trivalent, cold-adapted, live, attenuated influenza vaccine (Flumist) for use to prevent influenza A and B.  This approved indication is for healthy persons aged 5-49 years.  Inactivated influenza vaccine continues to be available and is indicated for persons aged 6 months and older who are healthy or who have chronic medical conditions.

The new vaccine is very costly compared with existing vaccines, and has not been shown to be more effective.  Flumist will only be reimbursable when there is medical necessity to receive the influenza vaccination in a non-injectable form, and when prior authorization has been obtained.  In order to request prior authorization for Flumist, you will need to submit an explanation and documentation of the medical necessity to the MaineCare Authorization Unit.  You may fax the information to (207) 287-7643 or call (800) 321-5557, option 5 if you have further questions regarding the Prior Authorization Process.  Questions regarding policy or billing questions should be directed to Provider Relations at 1-800-321-5557, option 9.

This article was prepared by MaineCare staff. [return to top]

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