January 9, 2006

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2006 Medicare Physician Payment Update and Claims Processing-Q and A
The House of Representatives is expected to act on Feb. 1 to halt the 4.4% Medicare physician pay cut that went into effect on Jan. 1. President Bush then is expected to sign the bill which would restore payments to the 2005 level shortly therefter.
While nothing can be guaranteed in Washington in an election year, most observers are confident that the House will pass the Senate-enacted bill (called the Deficit Reduction Act) in February and that the fees will be restored to the 2005 level.  CMS has also assured Congress that once the legislation is enacted and signed into law, Medicare's contractors will be instructed to automatically reprocess claims that were already processed reflecting the negative 4.4 percent update.  Physicians and other providers will not need to resubmit their claims in order to receive the higher payment.  In is anticipated that these payment revisions would be aggregated so that physicians and other providers receive one lump sum payment for the differential between payment based on the negative 4.4% update and the zero % update.  CMS expects that the reprocessing of claims would be completed by all contractors no later than July 1, 2006. The exact date would depend on the number of claims a contractor must reprocess.

Changes in the physician update would also impact the copayments and deductibles for beneficiaries, since copayment amounts may be greater that the amount originally billed.  Because routine waiver of copays can be considered fraud and abuse under the federal laws relating to improper  beneficiary inducements, the Office of the Inspector General (OIG) is being consulted by CMS and is expected to provide guidance. However, CMS has suggested in a letter to Congress that under these circumstances, a waiver of the additional cost-sharing amount would be unlikely to serve as an inducement to the beneficiary.  In many cases, these amounts would be less than $1.00.  Accordingly, short-term routine waivers of the additional, retroactive cost-sharing amount would not seem to constitute an improper beneficiary inducement.

Finally, because this change to the physician update could also affect a physician's decision regarding his or her  Medicare participation status for 2006, CMS plans to offer a second enrollment period for  physicians to reconsider any decision they may have made based upon the proposed reduction in fees. This enrollment period will run for an additional 45 days and will begin on or shortly after enactment of the legislation.  Should the physician decide to revise his or her participation election during this new enrollment period, the participation election will be retroactive to January 1, 2006

The AMA has prepared a Question and Answer document in order to answer some of the most frequently asked questions about this confusing and complicated situation.   

MeMGMA Presents Annual Third Party Payer Seminars

Maine Medical Group Management Association presents the annual Third Party Payer Seminars on:

Wednesday February 8, 2006
Ramada Conference Center, 490 Pleasant Street, Lewiston, Maine


Thursday February 9, 2006
Jeff’s Catering, 5 Coffin Avenue, Brewer, Maine

Seminar Schedules
Registration for both seminars begins at 8:30 AM - continental breakfast will be served
Sessions begin at 9 AM

A full Buffet lunch is included with the registration, with the final speakers concluding by approximately 4 PM.(Speakers from each insurance company may be presenting at different times each day, so an exact schedule is not available).

Space may be limited at both locations so please register as early as possible by phone or mail

Seminar Speakers
Provider Representatives from the major payers will be speaking at this seminar and providing updates as to the status of claims processing. We expect representatives from the following companies to attend:


** Brewer only

Participants will have the opportunity to ask questions concerning reimbursement issues affecting physician practices in general, but should not expect specific answers to questions concerning individual account situations.

Registration Information
The cost for this seminar is only $40 either day for any MeMGMA member or $50 per person for non-members


If you have any questions concerning this seminar, or for late registration, please contact Peter Allen at 1-800-640-0545

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CMS Hosts Physician/Part D Implementation Open Q&A Conference Call
A message from CMS:   Reminder: Please join CMS officials every Tuesday at 2pm EST for the Physician/Part D implementation Open Q&A conference call.  1-800-619-2457 Pass code: RBDML. This call is intended for physicians and other prescribers, we have similar weekly conference calls for pharmacies and long term care.

Medicare prescription drug coverage is here. Retail Pharmacies filled several hundred thousand Medicare prescriptions on January 1st alone. CMS staff and the PDPs have been working around the clock to fix problems and refine processes. Pharmacists have become "Part D experts" and have made the benefit work despite the inevitable challenges associated with a the first few days of a huge new program. The Centers for Medicare & Medicaid Service recognizes the important role physicians and other health care professionals have played in helping people learn about the new benefit and we appreciate your efforts this fall to help us raise awareness and educate people with Medicare about this new program. 

To help you care for your patients and easily obtain information about Part D formularies and whether a specific drug is covered by a Part D plan, Epocrates, Inc. has provided Part D formulary information through their free Epocrates Rx® software, which is available through their web-based system or hand-held PDA system.  This is online and operational as of now and can be accessed through www.epocrates.com .  For those physicians and office managers that don't use PDAs, Epocrates also has an easy to use web interface.  This free feature allows anyone to review formularies using any computer with an internet connection.  http://www2.epocrates.com/products/online/

CMS has also created a web-based formulary finder:  http://formularyfinder.medicare.gov/formularyfinder/selectstate.asp.  The CMS Formulary Finder provides a list of all Part D plans in a given state and links directly to a plan’s home page for a complete formulary.  It also provides general information about a plan’s drug utilization and appeals process.  In mid-January the CMS Formulary Finder will be linked directly to individual plan formularies.

It is important to note that during January all plans will have a transition process that will allow enrollees to continue their current drugs.  During this period, the physician can work with their patients to adjust drugs to new formularies or request formulary exceptions

We sincerely appreciate your efforts in helping us provide important prescription drug coverage to people with Medicare. [return to top]

2006 AMA State Legislative Strategy Conference
MMA sent four representatives to the AMA's 2006 State Legislative Strategy Conference this past week in Arizona.  President Jacob Gerritsen, M.D., Legislative Chair Katherine Pope,M.D. , EVP Gordon Smith and Deputy EVP and General Counsel Andrew MacLean attended the annual program which this year featured presentations and discussions on:

  • State Medical Liability Reform
  • Federal Patient Safety and Quality Improvement Act of 2005
  • Health Insurance Managed Care Payment Practices:  Strategies for State Legislative and Regulatory Advocacy
  • Scope of Practice
  • Medicare and other Federal Issues for 2006
  • Medicaid and Efforts to Cover the Uninsured
  • In-Store Clinics
  • Certificate of Need; Economic Credentialing and Hospital  Ownership of Physician Practices
  • Efforts to Facilitate the Delivery of Medical Care in the Wake of Disasters

Mr. Smith chairs the Executive Committee of the AMA's Advocacy Resource Center which organizes the yearly conference which attracts two hundred representatives of state and national medical societies.   He presented at the conference on the topic of hospital employment of physicians. [return to top]

The Coding Center Presents Major 2006 CPT and ICD-9 Changes Jan. 12, 2006
The Coding Center will present a coding round table conference call on Thursday, Jan. 12, 2006 on major 2006 changes in CPT and ICD-9.  The tele-conference will last two hours from 10:00am to noon and two CEU's are available for certified coders.

One phone call from your office and your entire staff can listen and participate.  The cost is $100 for Maine, New Hampshire and Vermont medical society member physicians and their staff, and $125 for non-members.  You should have 2006 CPT & ICD-9 books available during the call.

For a registration form to fax back, call the Maine Medical Association at 622-3374 (press 0 for assistance).

The instruction will be by Laurie Desjardins, CPC and Jana Purrell, CPC. [return to top]

122nd Maine Legislature Begins Second Regular Session
Last Wednesday, January 4, 2006, the 122nd Maine Legislature convened at the State House in Augusta for its second session amid brief political drama.  The day before the session began, a Democratic member of the House of Representatives, Barbara Merrill (D-Appleton), announced that she would leave the Democratic Party to become an independent.  She joined two other former Democratic House members who left the Party earlier in the year - Rep. Joanne Twomey (D-Biddeford) and Rep. Tom Saviello (D-Wilton).  These moves made the political composition of the House 73 Democrats, 73 Republicans, 4 Independents, and 1 Green Independent and had the House Republican leadership calling on Speaker Richardson to negotiate a power-sharing arrangement, including greater Republican representation on key committees, for the second session.  However, before any such negotations took place, Rep. Twomey announced her decision to return to the Democratic Party.

Following this brief diversion, the legislature will face the session's work - a supplemental budget, bills carried over from the first session (including one to reimburse providers for certain costs relating to the MECMS implementation), and new bills admitted through the Legislative Council.  Because the two legislative chambers are so narrowly divided politically and because it is an election year, the Dirigo Health Program will be a lively part of the health care debate, particularly the funding mechanism known as the "savings offset payment" or SOP.  The Governor's supplemental budget proposal may be released as early as the week of the Martin Luther King holiday.

The MMA Legislative Committee will hold its next meeting tomorrow evening, January 10, 2006 at 6 p.m. at the MMA office in Manchester.  The Committee will discuss the legislature's schedule, the Dirigo Health Program issues, and the bills printed to date.  Any interested member is welcome to attend.  Please RSVP to Charyl Smith, Legislative Assistant, at csmith@mainemed.com so we can include you in the meal count.  Also, the MMA will begin its weekly legislative email update, Political Pulse, this week.  If you would like to receive this summary of legislative activities, including action alerts on critical bills, please send your email address to Charyl. [return to top]

Update From Governor's Provider Advisory Group on MECMS Implementation
The Governor's Provider Advisory Group held its regular meeting to update members on the status of the MECMS implementation on Thursday, January 5, 2006.  The Department's usual table of Key Weekly Metrics for the week ending 1/1/06 showed the total claims processed to be 207,324 of which 84,854 were listed in "paid" status in MECMS (40.93%), 54,539 were denied (26.31%), and 67,931 were suspended (32.77%).  The total suspended inventory is 257,463 claims.  The Department has made interim payments in the amount of approximately $446 million of which the Department has recouped approximately $11 million.

As reported in today's MECMS Update #45 from DHHS, the Office of MaineCare Services (OMS) now has a temporary provider portal where you can check claim status within MECMS.  The portal enables you to see the status of all claims, at the header level, for all business statuses, including claims that are suspended.

The portal will be in place until DHHS can provide more extensive online access and make the full HIPAA transaction exchanges operational. 

This temporary solution does not provide line-level detail or explain why a claim suspended.  If you request additional information for individual billing numbers, for any specified dates of services and for any business status, DHHS will put that information in a results file in a secure online location for you to pick up.

To use the portal, you need to obtain a user ID and password.  Call the number included in the instruction manual available at http://www.maine.gov/dhhs/bms/innerthird/temp_prov_portal.htm.

At the OMS web site, www.maine.gov/dhhs/bms, you can download the MECMS newsletter, access information such as billing instructions, and sign up for the OMS listserve. 

The next meeting of the Governor's Provider Advisory Committee is scheduled for Thursday, January 19, 2006. [return to top]

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