January 23, 2006

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Governor Baldacci Features Healthcare in State of the State Address
Governor John Baldacci on Wednesday highlighted the State's efforts regarding Medicare Part D coverage and Dirigo Health initiatives in a nearly one-hour State of the State address. He also made a bold statement regarding the potential need for the state to establish its own health insurance company, an initiative that will be followed closely by insurers, public health advocates, employers and providers.
In summary, the Governor declared that the state of the state "is strong, secure and healthy."

With respect to Medicare Part D coverage, the Governor noted that Maine had stepped in during the difficult transition to assure that Maine Seniors previously covered under Medicaid or the Low Cost Elderly Drug program were protected and received the drugs they needed during the transition to federal Part D coverage.  Maine was the first state to take such action -to the tune of about $300,000 per day- and nearly 25 states have now followed suit by picking up the cost of prescriptions for low-income seniors and person with disabilities who were eligible for coverage but wrongly denied.  Nationwide, more than 6 million enrollees have been denied prescription drugs because pharmacists could not find their records in a new computer database or had incorrect information on how much to charge. The problem involved persons transitioning from the state programs to Medicare Part D, including approximately 45,000 Mainers.

Phone lines to the health plans contracted to provide the coverage were frequently jammed during the initial days of the coverage which began January 1.  The state, to its credit, stepped in and guaranteed payment for this vulnerable group and now will seek repayment from the federal government or the private health plans which have contracted to provide the coverage.

With respect to his Dirigo Health initiatives, the Governor praised the program and noted that Maine is one of only 11 states, and the only one in New England, that reduced the rate of people without health insurance during the past four years.  In his own words, "Our answer is two fold:  Dirigo works and Dirigo saves money.  Today, over 10,000 Maine people and 2,000 businesses across the state have enrolled in Dirigo Health.  We're expanding to cover more Maine families."

"Dirigo saves money.  Rate increases for small business are half what they cost last year.  The superintendent of insurance identified nearly $44 million in savings in the health-care system because of Dirigo.  Those are real savings that belong in your pocket, not in the pocket of an insurance company.  Therefore, I intend to support legislation to require insurance companies to pass those savings back."

"But that is not enough, we need to create transparency in the health insurance market so you know what you are paying for.  We are seeing success not only in the Dirigo Choice product, but in the broader Dirigo reforms.  We were successful a decade ago in creating a new solution to deliver workers' compensation - through Maine Employers Mutual Insurance Co.  Tonight, I am starting the process to make sure Dirigo can expand affordable coverage for more Maine citizens.  I have asked Steve Tringale, a nationally respected health insurance expert, to work with my health care team.  They will begin to examine if and how Dirigo can build a new model to deliver health insurance in Maine."

The Governor's remarks suggesting that the state move toward forming its own company may well be a reaction to the much expressed opinion in state circles that Anthem is unlikely to renew its two year contract to offer the DirigoChoice product (the current contract expires the end of 2006).  Given that  Anthem was the only bidder in 2004, the Governor may be hedging his bets in case Anthem walks.  Having the state form its own company may be the only means of continuing the product.  Republicans in the legislature can be expected to vigorously oppose the state forming its own company, with part of the mantra being that if the state can't run MaineCare, what makes it think it can operate a health insurance company.


MMA Server Down; Thursday, Jan. 19, 2006 Data Gone
MMA apologizes to those members and others who may have tried to send us an e-mail on Thursday, Jan. 19 through today.  The installation of a replacement backup drive near the end of the workday on Thursday crashed the MMA server.  Because backup had not yet been performed for that day, it is likely that that data from Thursday is unrecoverable.  We anticipate having the server up and running by Monday (today) after significant efforts to rebuild our system by internal IT staff and X-Wave Friday and over the weekend.

We apologize for the inconvenience, but any of you who may have sent something to us via e-mail the last four days should re-send it.  Many of you have called noting the inability to get a document to us. Again, our apologies.  [return to top]

Third Annual MMA Charitable Golf Tournament to be Held June 19, 2006
The Augusta Country Club in Manchester, Maine will once again be the site of the Association's Annual Charitable Golf Tournament.  The date is Monday, June 19th with registration and lunch beginning at 11:00am and a shotgun start at noon.  The beneficiaries of the net proceeds this year will be the five free medical clinics in the state operating in Biddeford, Portland, Brunswick, Rockland and Ellsworth.  Brian Jumper, M.D. will chair the tournament committee.  He will be assisted again by a group of mediocre golfers including Mr. Smith, Mr. MacLean and others not willing to be mentioned.

Registration materials will be included in the April issue of Maine Medicine but will also be mailed to all Corporate Affiliates and to any individuals who have played in the previous two tournaments.

Nearly 100 golfers participated last year.  We hope to have a full field of 120 golfers this year.  If you enjoy the sport, so to speak, consider putting together a team from your medical staff, your office or your specialty.

To receive an early registration form, e-mail Gordon Smith at gsmith@mainemed.com [return to top]

Two Coding Center Courses Being Offered Beginning in February
The Coding Center continues its popular education series with the following offerings:

     E/M Chart Auditing:  Offered six consecutive Thursdays from 8:00am to noon Feb. 23 through March 30 at the offices of the Maine Medical Association in Manchester, Maine.  The instructor is Jana Purrell, CPC, Director of the Coding Center.  24 CEU's are pending from the American Association of Professional Coders.  The cost is $600 per student.


  • Understand the elements of an audit
  • Issues surrounding documentation
  • Step by step auditing:  the key components
  • Helpful information about a variety of visit codes
  • Develop a template for your audit program


  • Basic knowledge of E/M principles
  • Experience with chart auditing helpful but not required
  • Coding Certification NOT necessary
  • Please bring CPT books to class!

AAPC Approved Professional Medical Coding Course:  Offered Wednesday mornings, March 1, 2006 through June 7, 2006 from 8:00am to noon at the MaineHealth Audit and Compliance office, 901 Washington Ave., Suite 104, Portland, Maine.   The certification exam will be held on Tuesday, June 13th at the same location.

This 15 week course, developed by the American Academy of Professional Coders (AAPC) will take students through the current 2006 Current Procedural Terminology (CPT), International Classification of Disease (ICD-9), and HCPCS books to address proper use and proper coding.  The class is intended to educate students on proper techniques and rules of coding and will also prepare them to sit for the AAPC Certified Procedural Coder (CPC) exam.

The cost is $1500 inclusive and includes the fees for the exam.  There is a prerequisite of two years coding experience.

Persons interested in either course may receive registration materials from the Maine Medical Association by calling 207-622-3374 and asking for the Coding Center.



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MaineCare MECMS Update
The MaineCare Providers' Advisory Group met last Thursday for its bi-weekly meeting and received a briefing on the on-going attempts to achieve full functionality in the MECMS system.  MMA had asked for the issue of the Part B crossover claims to be put on the agenda.  Overall, the process for payment electronically of the Part B claims is on track for a mid-March delivery date.  But that would still mean that checks would not be received until early April, at best.  Paper filing of crossover claims is still an alternative being offered.

Gordon Smith, MMA EVP continued to press state officials on the crossover payment issue, noting that most physicians have not been paid these payments since December of 2004.  "Even now, you are stating that it will likely be another 3 months before these claims are processed.  That is simply unacceptable," Smith stated.

MMA also is concerned about the April date inasmuch as virtually no other MECMS deadline has been met on time.  While reducing the claims to paper is taking a step backward in the attempt to automate, this would be our advice if you need to see these crossover amounts before spring.

The weekly metrics for the week ending 1/15/06 showed that 55.02% of claims submitted or recycled were paid, with 29.65% being denied and 15.34% being suspended.  242,690 claims remain suspended.

State officials did confirm that $4 million has been asked for in the supplemental budget to reimburse providers for their costs in dealing with the state's computer problem.  MMA will testify before the Joint Standing Committee on Appropriations and Financial Affairs on the need for these funds and more.

With respect to the interim payments recovery process and reconciliation, a second letter was mailed to 130 vendors and 279 providers on Jan. 13 and a mailing was planned for Jan. 20 to another 204 vendors and 530 providers.  All providers who may have received more in interim payments that their claims volume would support should hear from the Department by the end of the month.  Six persons currently staff the recovery and reconciliation office using e-mail, fax and phone to communicate with providers.  E-mail and fax communications continue to be the most efficient method of communication with them. The Department continues to be very flexible in dealing with practices that may owe funds subject to the recovery process.

With respect to the timely filing requirements, the Department is taking steps to expand the previous 12 month requirement to 17 months.  Providers could achieve certification for even an additional three months with evidence of routine submission.  Individual claims, with evidence of initial timely filing, may still be approved by the Provider Relation Specialists.

With respect to the current requirement that claims be resolved within one year from initial submission, the Department is simply removing this time requirement until Jan. 1, 2007.  Likewise, with respect to adjustments.

The new Prior Authorization (PA) portal is available at http://www.maine.gov/dhhs/bms/providerfiles/pa portal.htm.


The Claims status portal is up and running, as well, but there are some issues with corrections underway.  Provider Relation Specialists will be going to four locations to do portal related trraining in early February.

Providers are advised to work with their Provider Relations Specialist as a point of first contact, but providers should feel free to contact Karleen Goldhammer at 207-287-9238 or Karlene.Goldhammer@maine.gov if issues go outside of routine operational issues.

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State Law Requires Electronic Billing; Deadline to Request Waiver Extended to Jan. 31, 2006
A provision in the Dirigo Health legislation, enacted in 2003, requires all medical providers (including all licensed practitioners, not just physicians) to bill payors electronically.   A waiver provision was included, as requested by MMA and others, in order to accomodate those practices for whom electronic billing would be a hardship.  The waiver is only available for practices with fewer than 10 employees and was to have been requested by Oct. 16, 2005.

The waiver is based upon hardship which includes significant technological impediments, the cost of compliance or other unusual circumstances.

The Bureau of Insurance has extended the time period for a practice to request a waiver of the requirement until Jan. 31, 2006.  The application for the waiver is on the bureau's website which is at: www.maineinsurancereg.org.  Go to "Recent News" on the right hand side of the menu, scroll down to item 4 "Application" or review item 5 which includes freqently asked questions about the requirement.

MaineCare is exempt from the requirement as it is a federal program.  Medicare would be exempt except that a provision in the HIPAA legislation requires electronic submission to Medicare in any case, except for small practices.

There is no enforcement  provision in the Maine statute, but practices not billing electronically and not having a waiver could find themselves being denied payment by a carrier.  While MMA does not anticipate such a result, and will go to the legislature for assistance if this law unjustly enriches health insurance carriers, practices not billing electronically should apply for a waiver by Jan. 31. [return to top]

Date Changes in "First Fridays" Education Programs
Because of speaker availability, the Feb. 3 program on Physician-specific data is being postponed and will now be part of a program previously scheduled for June 2nd on quality.  Because of the program being offered by the Maine Chapter of the American College of Surgeons on June 2nd, we have moved the June 2nd program on data and quality to Friday, May 5.  The Coding Center program on Common Coding Errors, originally scheduled for May 5th will be held on June 2nd.  The April 7 offering on HIPAA will be moved to a later date, again because of speaker scheduling issues.

We have appreciated member and office practice support for the "First Fridays" educational programs offered at MMA and apologize for these changes in scheduling.  You may always receive the latest information on the schedule of seminars by simply calling MMA at 622-3374 or by e-mailing Gordon Smith at gsmith@mainemed.com or Gail Begin at gbegin@mainemed.com. [return to top]

Assessing Medical Practices for Quality; Any Volunteers?
MMA's Committee on Peer Review and Quality Improvement met on Jan. 17 and heard a presentation from Dennis Shubert, M.D. and Chris McCarthy from the Maine Quality Forum.  The Forum has asked MMA and the Maine Osteopathic Association to partner with it on a project involving asking medical practices in Maine to self-assess the quality of the care provided based on a series of metrics developed from various sources.  The assessments would be strictly voluntary and most importantly, the data derived shared only with the practice except for aggregate data that would be de-identified. At least initially, we would be working only with primary care practices.

Knowing how difficult it is for a practice to find the time to do such an assessment, the work would essentially be done for the practice by a health professional (probably a nurse hired to work on the project).  There would be no cost to the practice.  In fact, there may be sufficient funds to pay a practice for some of the administrative time spent on the project (which should be minimal given the role of the outside reviewer).

Before MMA enters into a potential contract to partner with the forum on this project, we are seeking practices to volunteer to be one of the practices participating.  This may be an ideal opportunity for some of the smaller primary care practices not currently participating in Pathways to Excellence.  Any practice that might be so interested should e-mail Gordon Smith at gsmith@mainemed.com. [return to top]

MMA Ad Hoc Committee on Health System Reform Considering Individual/Employer Mandates
In May of 2003, prior to enactment of the Dirigo Health legislation, MMA released a White Paper on Health System Reform that presented a number of proposals and recommendations aimed at increasing the number of insured individuals in the state.  At the urging of MMA President Jacob Gerritsen, M.D., the Association has called back into service the ad hoc committee and asked it to review the paper for relevance in 2006 and to consider specifically the issue of an employer mandate for large employers.  The committee held an initial meeting in early December and voted to break into three subcommittees to review the issues being considered.  

In conducting its review, the committee will look at some of the work being done in Massachusetts, Vermont and Minnesota, all of which are considering significant reform proposals.

Any MMA member wishing to participate should communicate with Dr. Gerritsen at jacobg@adelphia.net or Gordon Smith  at gsmith@mainemed.com[return to top]

Medicare Part D Information & Assistance from Legal Services for the Elderly
The new Medicare Part D prescription drug benefit became effective on January 1, 2006.  Beneficiaries, physicians, and other health care providers are adjusting to the new program.  Maine Legal Services for the Elderly, Inc. has a wealth of information about the new program oriented towards the provider community on its web site at:  http://www.mainelse.org/partd/Providers.

The web site also is a good resource for your patients.  It lists the organization's toll free assistance line, 1-800-750-5353. [return to top]

For Women Physicians Only: A Seminar Designed for You: March 3, 2006
Well over one-half of medical students currently enrolled are women.  Over one-half of the applications to medical school are from females.  In some specialties, notably Ob-Gyn, the percentage of women is even higher.  The Maine Medical Association has, for some time now, recognized the need to better relate to our women members.  As part of this effort, we are pleased to present a seminar designed just for women, entitled; "Negotiating for the Future:  Strategies, Tools and Skills You Didn't Learn in Medical School," presented by Harriet Nezer, PhD.

This highly interactive, women-only, seminar focuses on the power of aligning personal and professional goals and priorities with one's vision and values.  It will be presented on Friday morning, March 3rd at the offices of MMA in Manchester, Maine.  Enrollment will be limited to forty persons and the registration fee is only $60 which is the regular fee for our First Friday's CME programs.

Dr. Nezer is the founder and prinicipal of Metamorphosis Consulting and has over 20 years experience as an entrepreneur, learning specialist, consultant and coach assisting clients in health care, public safety, higher education and other fields.  Dr. Nezer earned her Doctorate in Education and Public Administration from Boston College and is currently adjunct professor and thesis advisor for Emmanuel College's Masters in Management Program.

Registration materials will be included in an insert in your Jan.-Feb. issue of Maine Medicine, but you can reserve a space today by calling Gail Begin at 622-3374 (ext. 210) or by e-mailing her at gsmith@mainemed.com. [return to top]

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