December 12, 2005

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Update on MaineCare Claims Processing (MECMS)
The MaineCare MECMS system is functioning well enough, the Department believes, to begin the process of reconciling interim payments with claims submitted. But the Department staff have promised to start slow and to only work initially with those providers whose claims are now being paid on a reliable basis. Only 300 providers will be receiving the initial letter going out this month, describing the reconciliation/recovery process.
The Governor's Provider Advisory Committee on MECMS met this past Thursday and received an update on the operation of the system and the Department's plan to begin a reconciliation and recovery process for those providers who have received interim payments.  Over $422 million in interim payments have been made through 12/04/05.

About 300 providers will receive a letter later this week intended to "reassure and inform providers who have already begun to hear that the interim payment reconciliation and recovery process will be launching soon."  The Department states that the reconciliation/recovery process will be sensitive and responsive to the concerns of providers and will be targeted only to those providers whose claims are being reliably processed and whose concerns regarding suspended claims and other issues are being addressed.  Only providers in this position will be the initial focus of the process and most of these providers have already been in communication with Department staff. 

The select group of providers receiving this initial letter will be presented with three options if they have received an overpayment as a result of the interim payments.  They may send a check in for the amount owed, or they may elect to have 50% or 75% of their future remittances withheld. Once a percentage is selected, it must remain current for the duration of the process.  If no election is made, 75% will be automatically selected as the default.  If it is determined after the process begins that the selected rate of repayment will not settle the full interim amount owed within 90 days, the State may contact the provider to modify the interim payment methodology.

The reconciliation process is expected to begin for this initial group before the end of December.  If you are part of this initial group, you can contact the Office of MaineCare Services at 207-287-5001 with any questions or concerns.

Early in 2006, a larger group of providers will receive a similar letter,  but again, the process of reconciliation and recovery is targeting only providers meeting the above criteria, i.e., those who are receiving accurate payments on a reliable basis.  The state has indicated a willingness to also consider financial hardship and will take into account providers' claims payment issues, such as claims still in suspension, during the distribution of the letters and will create an exception process to deal with such matters.

Cross-over payments (Part B).  Cross-over payments for dual-eligible patients are now able to be processed on paper.  Full functionality regarding electronic submission of such claims should be reached in late February or March.  Whether you chose to file on paper if you have previously filed electronically should depend on the amounts owed and whether you can afford to wait.

The key weekly metrics report for the week ending 12/04 showed that 71.93% of new claims were paid, with 13.87% being denied and 14.20% suspended.  Over 300,000 claims remain in suspension with the goal being to reduce this amount to below 250,000 by the end of the year.

As reported in last week's Weekly Update, the Commissioner of the Department of Human Services has asked the legislature for $4 million to reimburse providers for the increased costs associated with the failure of the MECMS system.  Be sure to keep track of expenses over and above your usual claims processing expenses as these records may be required if the appropriation comes through.  MMA has continually advocated for reimbursement of these costs by the state.

MQF Advisory Council Endorses Amendments to Sentinel Event Law
At its meeting on Friday, December 9, 2005, the Maine Quality Forum Advisory Council voted to endorse a 4-1 ad hoc subcommittee recommendation for proposed changes to Maine's mandatory sentinel event reporting law, P.L. 2003, Chapter 678, enacted in 2003.  There was one vote against the recommendation and one abstention.  The ad hoc subcommittee's recommendations are:

  • Add the National Quality Forum's never events to Maine's sentinel event reporting statute.
  • The sentinel event team annual report shall confirm completion of planned corrective and preventive actions related to previous reported events.
  • Through rulemaking, require providers to use the sentinel event taxonomy developed by the JCAHO and endorsed as a national voluntary consensus standard by the National Quality Forum.
  • Allow the state to forward de-identified summaries of Maine's events to Patient Safety Organizations recognized by the federal Patient Safety Act of 2005.
  • Require the Division of Licensure & Certification to adopt a protocol to assess compliance with the sentinel event statute.
  • Encourage the sentinel event team to follow up and collect data on implementation of provider planned system corrections to system failures responsible for prior sentinel events.
  • Provide the sentinel event team and the Division of Licensure and Certification adequate resources to fulfill these recommendations as well as its existing statutory mandates.

Rep. David Trahan (R-Waldoboro), the prime sponsor of the bill creating the system, filed a minority report essentially arguing that the current system is working well, that it is too soon to amend the law, and that it is too risky to submit legislation to make these changes because it would give legislators an opportunity to challenge the confidentiality protections in the current law.

Dr. Dennis Shubert, Director of the MQF, must submit these recommendations to the Governor's Office of Health Policy & Finance (GOHPF) and the Governor may or may not choose to submit a bill during the Second Regular Session of the 122nd Legislature.

The Advisory Council also reviewed a projected project cost proposal for 2006, including $200,000 for a Population Based Practice Assessment project that would work through the MMA and MOA in order to obtain peer review protection.  The project would use existing validated tools and would include a patient survey and chart review.  The MQF would compile data and produce a report of aggregate data.

Later on Friday, the MQF Performance Indicator Committee engaged in a lengthy discussion of Ambulatory Care Sensitive Condition (ACSC) Discharges for Maine hospitals.

The MQF Advisory Council next will meet on Friday, January 13, 2006. [return to top]

Blue Ribbon Commission on the Future of MaineCare Reviews Draft Report
At its meeting on Tuesday, December 6, 2005, the Blue Ribbon Commission on the Future of MaineCare reviewed a draft report comprised mostly of background materials and work of the federal Medicaid Commission.  The report also included a list of potential recommendations by the federal commission, by the National Academy for State Health Policy, by DHHS, and by members of the Commission.  The list includes changing prescription drug reimbursement formulae, amending the funding for long-term care, "pay-for-performance," selective contracting, and using managed care techniques for high-cost and other special populations.  The Commission will meet once more on Wednesday, December 14, 2005 to finalize its recommendations.  The Commission includes four legislators, 2 Democrats who chair the group and 2 Republicans, and 6 members of the public. [return to top]

MAC Briefed on State Plan for Medicare Part D Autoenrollment
Maine physicians recently have seen patients who are either dually-eligible for MaineCare and Medicare or participants in the Low-Income Drugs for the Elderly & Disabled Program (DEL) bringing in letters notifying them that they have been "auto-enrolled" by the government in a Medicare Part D prescription drug plan or PDP.  In fact, both the federal government and the state government have sent these "auto-enrollment" letters.  Auto-enrollment of these beneficiaries is necessary if they do not choose a PDP on their own because their existing drug benefits will end on December 31, 2005. 

The federal auto-enrollment letters went to beneficiaries earlier than the state letters.  DHHS staff briefed members of the MaineCare Advisory Committee on the State's auto-enrollment process during its regular meeting last Tuesday.  DHHS recently has sent letters notifying these beneficiaries that "[b]y the middle of December, the State will automatically assign you to a Medicare Prescription Drug Plan that:

  1. best meets your current drug needs based on the information we have about drugs you have been taking during the past three months,
  2. has a pharmacy in your community, and
  3. requires the lowest co-payments from you when you pick up your drugs."

DHHS is completing the contracting process with PDPs and should be able to notify providers, beneficiaries, and the public of the PDPs chosen to provide Part D coverage for the "dual eligible" and DEL populations this week.  The State expects to complete the auto-enrollment process by December 15, 2005. 

While the Part D benefit is confusing and this auto-enrollment process for "dual eligibles" and DELs is particularly confusing, it is critical that the beneficiaries are enrolled in a PDP having a contract with the State by the end of the month so they do not lose coverage.  They can change PDPs, if necessary, once enrolled.

The Maine Primary Care Association is working with MaineCare to offer trainings specifically for MaineCare prescribers.  The list of scheduled trainings is:

December 13:  Farmington, location TBA, 10:00 - 11:30 a.m.

December 16:  Portland, MMC/Dana Conference Center, 7:30 - 9:00 a.m., 5:30 - 7:00 p.m.

December 19:  Augusta, MaineGeneral Medical Center, 7:30 - 9:00 a.m.

There also will be a make-up session in Lincoln, date & location TBA

To register, please email Andrea Watkins at [return to top]

DHHS Commissioner John R. Nicholas Announces Resignation
Maine Department of Health and Human Services Commissioner John R. Nicholas announced his resignation last week noting his desire to spend more time with his family.  Commissioner Nicholas, a former Chief Budget Officer for the State, has served in the position since early 2004 and oversaw the merger of the Department of Human Services and the Department of Behavioral Health.  Deputy Commissioner Brenda Harvey has been named acting Commissioner and will take over the Commissioner duties sometime in January.

While the Department has certainly had its share of controversies and problems during the Commissioner's term, many of the most serious problems were inherited and MMA is sorry to see him leave.  Commissioner Nicholas has always been accessible to MMA representatives and most recently attended the Association's Annual Session in Sept. with his wife Nancy.

MMA wishes the Commissioner all the best in whatever his future holds. [return to top]

Gerritsens to Host Fundraising Event for Governor Baldacci Jan. 2, 2006
Jacob Gerritsen, M.D. and Terry Gerritsen, M.D. will host a fundraising reception for Governor Baldacci's re-election campaign on Monday, Jan. 2 from 5:30pm to 8:00pm at their home on 55 Clay Brook Rd., in Camden.  Co-hosts include Maroulla Gleaton, M.D., Robert Keller, M.D., Lawrence Mutty, M.D., Danielle Mutty, M.D., Erik Steele, D.O., Samuel Solish, M.D., Jo Linder, M.D., Neil Smith, M.D., Paul Killoran, M.D., Betty Killoran, M.D.,Edward David, M.D., Steve Shannon, D.O., Bruce Sigsbee, M.D.,  and Ted Steele, M.D.

Watch for your invitation in the mail later this week.  Directions to the Gerritsen home will be included with the invitation and reply card. [return to top]

Quality Counts III A Big Success this Past Week
Quality Counts Part 3, "Pulling It All Together", was attended by about 250 persons last Tuesday who spent the day at the Augusta Civic Center hearing plenary session talks and breakout sessions which focused on the Chronic Care Model.  Governor Baldacci opened the conference.

The keynote speaker was David K. McCulloch, M.D., FRCP, an international expert in diabetes care from Group Health Cooperative in Washington State.  He also holds a teaching position at the University of Washington, Seattle.  Dr. McCulloch was quite generous in his praise for the current efforts in Maine to improve care through the use of the chronic care model.

William Taylor, M.D., MPH, Associate Regional Administrator, Boston Regional Office and Director, Division of Quality Improvement, CMS, presented attendees with information on the CMS effort to advance quality including the new reporting program scheduled to begin in 2006.

The last presentation of the afternoon focused on the integration of physical and mental health, focusing particularly on the treatment of depression.

Ten breakout sessions were held in the morning, with topics ranging from "Group Visits and the Team Approach to Chronic Illness Care" to "Connecting Centricity Physician Offices to Pay-for Performance and Quality Activities.''

Quality Counts is a collaborative project promoting transformational change needed to improve chronic illness care and prevention.  Congratulations to Lisa Letourneau, M.D., MPH, who moderated the day's program and to all the Quality Counts participants on another successful conference. [return to top]

Dan Hanley Memorial Trust is Now the Daniel Hanley Center for Health Leadership
The Board of Directors of the Dan Hanley Memorial Trust met this past Wednesday and approved new corporate bylaws.  Among other changes, the corporation will now be known as the Daniel Hanley Center for Health Leadership.  The Board, currently chaired by Sean Hanley, M.D., heard from Executive Director James Harner of the planned dates for the 2006 Hanley Forum (June 15-16) and of plans for the inaugural class of Hanley Fellows.  The Fellows program has been developed by a committee with the goal of identifying a small number of emerging leaders in health care across the state and pairing them with experienced mentors for a 24-month long development program.

The Trust (now the Center) were founded by the friends and family of the late Daniel F. Hanley, M.D., who among his many activities, served as Executive Director of the Maine Medical Association for 25 years, retiring in 1978.  He also was the founder of the Maine Medical Assessment Foundation, the Bowdoin College physician and a leading medical presence on the US. Olympic Committee.

Persons interested in the Hanley Forum, the Fellows Program or any other Center activity may contact Mr. Harner at 207-523-1501 or go to [return to top]

2006 First Fridays CME Programs Kick Off with Jan. 6, 2006 Program on Medical Practice Compliance
The fourth "First Fridays" presentation was held on Friday, Dec. 2 with about 30 attendees hearing encore presentations from the 2005 Physician Survival Seminars.  Many thanks to the presenters Michael Duddy, Esq., John Gleason, Esq., and Margaret Palmer, PhD., who presented on the topics of managing the unruly patient, employment law, and managing the angry physician respectively.

The next First Friday program will be held on Friday, Jan. 6, 2006 on the issue of Medical Practice Compliance, focusing on the need for a compliance plan in every physician office.  A sample compliance plan will be distributed and practical advice will be offered on how to draft and implement a plan for an office your size.  Speakers will include former U.S. Attorney Jay McCloskey, attorney Kenneth Lehman and an assistant Attorney General.  The program will be held at the MMA offices in Manchester from 9:00am to noon.  The cost is only $60 which includes breakfast and all the course materials. The tentative agenda is below.

9:00 am   The Why and How of a Medical Practice Compliance Plan:  Jay McCloskey, Esq.
          Former U.S. Attorney Jay McCloskey will discuss the model compliance plan for an individual and small medical office practice released by the federal DHHS Office of the Inspector General in 2000. Mr. McCloskey will specifically address why it is important to have a plan and live by it, including the benefits that accrue if a practice gets into difficulty and has a plan.

10:00 am  Specific Issues in Maine Requiring Attention: Kenneth Lehman, Esq.
          Former Assistant Attorney General Kenneth Lehman representated the Board of Licensure in Medicine for many years prior to establishing a private law practice in Portland.  He specializes in representing physicians and other health providers before licensing boards and regulatory agencies.  In this hour, Mr. Lehman will focus attention on some of the lesser known areas that can quickly get a physician or medical practice into trouble. 

11:00 am  A View from the Boards and State Agencies
         An Assistant Attorney General will present the view from his or her office regarding the need for a compliance plan.

Watch for an insert in the Nov.-Dec. issue of Maine Medicine which will include the registration material for this program and a list of all the programs offered throughout the year.  More information and registration can also be handled by calling Gail Begin at MMA at 622-3374 (X 210) or via e-mail to

The Association developed the First Friday series of educational programs in response to feedback from members and practice managers who expressed the need for these types of programs in a half-day setting.  Suggestions for future topics can be sent to Gordon Smith at [return to top]

Urge Maine's Congressional Delegation to Fix Medicare Payment Formula
Congress now returns to work in Washington after the Thanksgiving break and will focus on budget reconciliation efforts.  Urgent action on the Medicare SGR formula is necessary as part of this work.  The U.S. Senate has acted to increase Medicare payments to physicians by 1% in 2006, but the House has not yet acted.  If Congress does not act soon, Medicare will cut physician reimbursement by 26% during the next 6 years - including a 4.4% cut on January 1, 2006.  These cuts threaten patients' access to care, as many physicians will be forced to decrease the number of new Medicare beneficiaries they can treat.

Please contact members of Maine's Congressional delegation to urge their support for the Medicare SGR fix.  You can compose an email message on the AMA's Grassroots Action Center website at:

Or, you can call the members' offices at the following numbers:

Senator Olympia Snowe:  202-224-5344

Senator Susan Collins:  202-224-2523

Representative Tom Allen:  202-225-6116

Representative Mike Michaud:  202-225-6306 [return to top]

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