December 18, 2005

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Clock is Ticking on Medicare Physician Payment Fix by Congress by Year End
Congress needs to act this week on a $50 billion budget bill if the Jan. 1, 2006 reduction of 4.4% in physician fees is to be averted. Time is running out.

The clock is ticking as Congress tries to wrap up a $50 billion budget package before leaving for the Holidays.  As this article is being prepared, Congress is still working through the weekend but most assuredly will return home  by the end of this week.  At stake is Medicare physician payment and imposition of a new pay-for-performance system.

If Congress does not act by Dec. 31, Medicare rates to physicians and other individual practitioners will be reduced by 4.4%.  Congress is also considering a pay-for-performance measure included in the Senate package that would potentially lead to further cuts.

MMA, the AMA and your national medical specialty societies have worked hard to avoid this potential cut.  If you have not contacted members of the Maine Congressional delegation on this issue, this is your last chance to do so.  While Senators Snowe and Collins and Congressmen Allen and Michaud have all expressed strong support for fixing the payment problem,  the shortness of time, the necessity of finding $ for the fix and the difficult political environment in Washington currently may converge to deny passage of the $50 billion budget bill that is the only likely vehicle available to fix the problem by the end of the year.

MaineCare MECMS Update: Important Follow-up to Last Week's Update
In our continuing effort to keep members and their staffs up to date on the MaineCare claims processing issue, last week's Maine Medicine Weekly Update contained information about the Department's interest to begin reconciling interim payments with claims and to recover any amounts that were overpaid.  Unfortunately, the telephone number given for persons to call with questions was not ready for prime time and some callers were not assisted.  The number will be ready soon and when it is, we will share the number again with members.  It will now be January before all providers receive a letter (Letter 1) informing them that the interim payment reconciliation process will be commencing but will be initiated for a given practice only when it is determined that its claims are processing appropriately.

The following statement has been provided to MMA by the state to explain the current situation:

We wanted to clear up some possible misconceptions regarding the communications process relating to the interim payment reconciliation between the State and the provider community.


The challenges presented to the providers and the State in dealing with interim payment reconciliation are numerous, and many potential questions and concerns of providers are difficult to anticipate.  Because of this, it is essential that the information shared with providers is clear, and the reaction of providers is appropriately tracked.  The communication process is being initiated in phases, to determine the appropriate number of staff and the level of training and expertise needed to address provider concerns and questions.


During the next month, all providers will be receiving a letter (Letter 1) letting them know that the interim payment reconciliation process will be commencing in the near future.  This letter is basically a “heads-up” and meant to assure providers that the process will be fair, seamless, and will be initiated for a provider only when it is determined that their claims are processing appropriately.  Although the letter is intended to generate no specific reaction, it is anticipated that a number of providers will have questions or concerns.  Because of this, staff is currently being developed and trained to appropriately respond to providers’ questions and a phone number will be included with the letter.  In the interest of making sure that the providers receive the appropriate level of responsiveness, the State will be releasing 300 of these letters to test provider reaction and identify the appropriate staffing needs.  Subsequent to gauging provider reaction, Letter 1 will be sent out to the rest of the provider community. 


It is our understanding that the phone number to be included on Letter 1 has been shared with a large number of providers.  Unfortunately, at the time of the release of the phone number, the staff had not been appropriately trained to field questions related to interim payments causing some concern from providers who tried to use that number.  Please be assured that training is currently occurring that will allow the staff to properly answer a variety of provider questions when Letter 1 is officially released to the provider community.


Shortly after the release of Letter 1, the general reconciliation process will begin for groups of providers who have been identified as having their claims processing correctly for a specified time period and who no longer need to rely on interim payments.  When a group of providers is deemed ready for interim payment reconciliation, they will receive a second letter (Letter 2) from OMS notifying them when the interim payment recoveries will begin, along with a detailed history of the interim payments they have received or returned.  Under the current plan the providers will be given the choice of submitting a check to OMS for the full amount due, or having their remittances reduced by 50% or 75% until that full interim payment amount has been repaid.  It is anticipated that an initial group of providers will be receiving Letter 2 by the end of December.  The State will make every effort to be flexible for providers who would experience financial hardship during the recovery process.

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Important Information for MaineCare Providers Wishing to Repay Interim Payments Prior to Year End
On Dec. 14, 2005, the state sent a notice to MaineCare providers, establishing a process for those providers who might wish to reconcile interim payments with claims prior to the end of the year.  The state will provide any such practice with their interim payment history, but the request for such needs to be made by Dec. 20th.  In such a case, the provider can expect to receive an e-mail containing their interim payment history by the end of the day on Dec. 23.

For providers who wish to have their interim payments repaid to the State for the purpose of their year-end financials, the State must receive the check by Dec. 27, 2005.  Providers are asked to send their repayment request to:

You must include the following information for all provider numbers you intend to settle prior to year end:

1.  All MECMS provider ID number (s) for which settlement information is needed.

2.  A return email address that may be used to respond to the request including contact name and phone number.

If you receive any additional unsolicited interim payments, please return the check to:

                                                     Attn:  Colin Lindley

                                                     Office of Management and Budget

                                                      11 State House Station

                                                      211 State St.

                                                      Augusta, Maine 04333-0011 [return to top]

MMA to Review White Paper on Health System Reform Through ad hoc Committee meeting, Dec. 21.
In March of 2003, the Maine Medical Association released a White Paper on Health System reform that endorsed an individual health insurance mandate as the primary means of achieving universal access to health insurance in the state.  The position paper was prepared by physicians serving on an ad hoc Committee on Health System Reform, chaired by Maroulla Gleaton, M.D.  The White Paper was also endorsed by MMA's Executive Committee.

Given the significance of the debate in Maine on the Dirigo Health initiatives and MaineCare over the past two years, the Association's leadership believes it is time to review the White Paper and to update it, if necessary.  One of the specific issues to be reviewed will be whether to add to the paper a mandate that large employers offer health insurance to their employees.

The ad hoc Committee has been reassembled and some new members added.  If you would like to be involved with this committee, contact Gordon Smith at MMA via e-mail to  The Committee will meet this coming Wednesday night at 6:00p.m. (dinner will be available) at the Association offices in the Frank O. Stred building in Manchester.

Members not wishing to serve on the committee but wishing to provide input through comments should send them to Mr. Smith at the above address or directly to the Association's President, Jacob Gerritsen, M.D. at


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Insurance Bureau Extends Deadline for Waiver of Electronic Claims Filing Requirement





Title 24 M.R.S.A. sec. 2985 requires health care practitioners who directly bill for health care services to submit claims in electronic data format to a carrier, and provides that health care practitioners or groups of health care practitioners with fewer than 10 full-time equivalent employees are exempt until October 16, 2005.  Insurance Rule Chapter 825 permits practitioners with fewer than 10 employees to apply to the Superintendent for a hardship exemption for submitting electronic health claims if there are significant technological impediments that make it difficult for the health care practitioner to submit claim forms electronically, the cost of compliance would have a significant impact on the health care practitioner, or granting the waiver is warranted based on other considerations or unusual circumstances.  Insurance carriers may not be required to accept a claim that is not submitted electronically, except from a health care practitioner who is exempt pursuant to section 2985.

For most practitioners the cost of filing claims electronically is modest and in many cases electronic filing results in faster claim payment.  Although we anticipate that most practitioners will take advantage of electronic claim filing, we have found that many small health care providers were not aware of the electronic claim filing requirements.  Therefore, the time for requesting a hardship exemption has been extended to January 30, 2006.  Procedures and forms for requesting a hardship exemption can be found at


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MMA Group Health Plan Increase 1.4%, Effective Feb., 1, 2006
The renewal negotiations with Anthem Blue Cross and Blue Shield of Maine have successfully concluded with the premium increase being only 1.4% for the coming year, beginning Feb. 1, 2006.  As the MMA group plan does utilize age banding, an increase in an age band would result in an effective increase of 6%.

This modest increase, including the Dirigo Health associated "savings offset payment", is the lowest increase in a number of years.  It will be a welcome relief to the participants in the program, particularly those retired physicians on fixed income who have suffered through significant increases in the Medicare Supplement product.

Members or staff interested in the plan should contact the brokers, HRH, formerly the Dunlap Agency, at 1-800-464-1203 x1103 (Judy Conley).   MMA also maintains a dental plan for members and staff through Anthem, with HRH also being the brokers for the plan. [return to top]

Pay for Performance Starting Slow with Mixed Responses
A Dec. 14, 2005, news release from the Centers for Studying Health System Change reports that pay-for-performance (PFP) is having a slow start in many communities across the country and that physician responses are ranging from support to resistance.  You can link to the news release here:  Also, embedded in the news release is the Center's Dec. 2005 issue brief, "Can Money buy Quality?  Physician Response to Pay for Performance" [return to top]

Medicare Part D Exception and Appeal Form now Available; Formularies on ePocrates Jan 1, 2006
With some seniors having coverage effective Jan, 1, 2005, physician offices have only a short time to get up to speed on the Medicare Part D coverage.  Forms for seeking an exception or appeal related to coverage can be obtained  from Susan Lutton at Legal Services for the Elderly via

All Medicare Part D formularies will on ePocrates effective Jan. 1, 2005.  Nancy Morris of the Maine Health Alliance will be holding some training sessions in the Portland area for Palm/ePocrates users.  You may contact Nancy at for further information about the training. [return to top]

State Officials Gather to Plot Strategy on Pandemic Flu
State Health officials and providers gathered in Augusta last Wednesday to discuss ways to avoid a pandemic flu spreading throughout Maine.  The Maine Pandemic Influenza Plan was presented and then the assembled physicians, hospital executives and emergency planning officials  broke into smaller groups to try to figure out a way to keep it the dire scenarios from coming true.

Once a new strain of flu is identified, it should take one to six months for the pandemic flu to reach the U.S.  The outbreak would be prolonged and slow moving, taking up to eight weeks to play out.  Nonetheless, outbreaks are predicted to begin almost simultaneously across the country.

More than 200 persons attended the day-long session at the Augusta Civic Center to discuss appropriate responses.

The state Center for Disease Control and Prevention has been working on a response to a flu pandemic for several years.  A report was issued in August regarding the state's role and several staff attended a conference in Washington earlier this month to learn of federal plans. Next on the docket is to draw up a list of needs and problems and to convene local meetings around the state.

If avian flu strikes Maine, the plan calls for the Governor to declare a state of emergency and assume leadership, guided by the Maine CDC and the Maine Emergency Management Agency.  The governor's orders would be passed on to county-level emergency management officials, and then to municipal leaders.

MMA President Jacob Gerritsen, M.D., an internist from Camden, represented MMA at the conference. [return to top]

Seat Belt Use in Maine Increases
Mainers increased their use of seat belts by over 2% from 2004 to 2005, according to the federal traffic safety agency.  Maine increased its use from 72.3% to 75.8%, being one of thirty-four states which increased their use over the same period of time.  The national average is now 82%, so Maine is still lagging behind many other states.  Passage of a primary enforcement measure would be the most effective means of Mainers using their seat belts, observed Gordon Smith, Esq., MMA's Executive Vice President.  "Unfortunately, the state legislature has not yet seen fit to enact such a requirement, although I'm certain we will try again in 2007," he noted. [return to top]

Looking for Interested Physicians to Serve as Physician of the Day in Augusta
The Maine Medical Association and the Maine Osteopathic Association are looking for interested physicians to participate in the "Doctor of the Day" program.  The second session of the 122nd Legislature opens on January 4, 2006 and will continue into April 2006.  The program is an important part of the MMA and MOA's attempts to maintain regular physician/legislator interactions on the state level.  The program is now in its tenth year and all available residents and physicians are encouraged to volunteer for this worthwhile program.

As "Doctor of the Day", each physician is given a tour of legislative areas of the State House including House and Senate chambers and committee rooms.  The physician is introduced in both chambers of the Legislature and then given the opportunity to touch base with legislators, tour the area and attend public hearings when available.  Physicians are also given a pager in case of an emergency in the State House though only minor response is required because emergency services follow rapidly.

An additional part of the program encouraged by MMA and MOA  is the State House page program.  Children of our physicians assist the legislators in the House/Senate chambers by serving as pages to distribute materials in the chambers.  It is a positive program to teach children and young adults about legislative process.

Please take the opportunity to contact Charyl Smith, Legislative Assistant at 207-622-3374 ext 211 or to register for the upcoming session. [return to top]

Update on Medicare Part D Auto-Enrollment of Dual-Eligibles & DEL Members
This week the Department of Health & Human Services will be sending auto-enrollment letters to Medicare/Medicaid dual-eligibles and beneficiaries of the Low-Cost Drugs for the Elderly & Disabled Program (DEL).  The letters will be staggered over a 5-day period in an attempt to hold down the number of calls and questions coming into the Pharmacy Help Desk 1-866-796-2463 line, and inquiries to you.  The following is a list of Prescription Drug Plans (PDPs) that have agreed to contract with the State to cover these two populations and to provide extra help to beneficiaries regarding the "wrap around" state services outlined previously in MMWU. 

State List of Contracted Prescription Drug Plans (PDPs)


Anthem - Blue MedicareRx Value

CIGNA Healthcare - CIGNATURE Rx Value

First Health - First Health Premier

Fox - Fox Rx Care

Member Health - Community Care Rx Basic

PacifiCare - PacifiCare Saver Plan

Rx America - Advantage Freedom Plan

Caremark - Silverscript

Unicare - Medicare Rewards

United Health - AARP Medicare Rx Plan

WellCare - WellCare Signature

The State recently has faxed physicians a Medicare Part D Question & Answer Forum (FAQ) and expects to update that early next week. [return to top]

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